october 4th diagnosing hepatitis delta presentation title ...€¦ · presentation title •...
TRANSCRIPT
Presentation Titlebull Prepared for Organization | Date
Diagnosing Hepatitis Delta
in the US
Dr Robert Gish
Medical Director Hepatitis B Foundation
Dr David Hillyard
Medical Director Molecular Infectious Diseases ARUP Laboratories
October 4th 2017 1200 PDT 300 EDT
PhoneAudio Option
United States +1 (213) 929-4232
Audio PIN Shown after joining the webinar
Access Code 642-605-645All attendees are muted
Questions Feel free to submit questions in the chat box at anytime throughout the webinar
Questions
Disclosures
bull Dr Robert Gish is a Medical Consultant for Eiger Pharmaceuticals
Epidemiology of Hepatitis DeltaKey messages
An estimated 15-20 Million individuals are infected with HDV worldwide
Hepatitis Delta is the most severe form of chronic viral hepatitisrarr No testing ndash no identification of HDV infection
The clinical manifestations of hepatitis delta differs between regions and has changed during the last 3 decades
Hepatitis Delta is a dynamic disease - Both HBV and HDV contribute to disease progression
Migrant populations and special risks groups show particular high HDV prevalence
The HDV genotype matters
After H Wedemeyer
HDV Significance
bull HDV infection is associated with
ndash Increased liver disease severity in setting of both superinfection and coinfection with HBV
ndash More rapid rates of disease progression and early cirrhosis
Wang-Huei Sheng et al Clin Infect Dis 2007 Apr 144(7)988-95 Epub 2007 Feb 20
ndash Increased risk of HCC (up to 3x fold in HBV-cirrhosis)
Fattovich G Giustina G Christensen E Pantalena M Zagni I Realdi G SchalmSW Influence of hepatitis delta virus infection on morbidity and mortality in compensated cirrhosis type B The European Concerted Action on Viral Hepatitis (Eurohep) Gut 200046420ndash426
HDV Virology
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HDV Transmission requires HBsAg
HDV Epidemiology
Mario Rizzetto Cold Spring Harb Perspect Med 20155a021576
HDV = delta-virus delta-agent Always found in association
with HBV-infection Worldwide infection asymp15-20
million The most common routes of
transmissionndash intravenous transmission (IDU)ndash percutaneous transmission (tattoo
piercing)ndash sexually transmissionndash intrafamilial transmission
Endemic regionsndash Mongoliandash Mediterranean countries (most
often in children and young people)ndash Far East (infectiousness varies from
90 among HBsAg-carriers living in the Pacific Islands up to 5 HBsAg-carriers in Japan)
ndash Amazonia
HDV TESTING RECOMMENDATIONSamong HBsAg+ Individuals
bullAASLD Guidelines ldquoLaboratory tests should include assessment of liver disease markers of HBV replication and tests for coinfection with HCV HDV or HIV in those at riskrdquo which includes all individuals from HDV endemic areas and those with history of IDUrdquo
bullEASL Guidelines ldquoOther causes of chronic liver disease should be systematically looked for including co-infections with HDV HCV andor HIV (A1)rdquo
bullAPASL Guidelines ldquoOther causes of chronic liver disease should be systematically looked for including coinfections with HDVrdquo
Different HDV Genotypes in Different Regions
Wedemeyer amp Manns Nat Rev Gastroenterol 2010
Hughes et al The Lancet 2011 Abbas et al World J Gastroenterol 2012
Prevalence of Hepatitis Delta by Genotype in the Asia-Pacific Region
Country Prevalence Author Poster
No
India 152
109
Raja WA et al
Asim M
82
8
Korea 04 (OLT) Jung Y J et al 47
Pakistan 352
453
400
453
Mumtaz K et al
Zaki M et al
Bhatti TA et al
Memon M S et al
71
7
13
95
Iran 76 Azinmehr L et al 11
Turkey 25 (Izmir)
34 (Izmir)
8 (SE)
9 (Ddiyarbakir)
Koumlse S et al
Akpinar Z et al
Turhanoglu M et al
Gulsun S et al
26
40
41
58
EASL Monothematic Conference Delta Hepatitis 2010
Prevalence of Hepatitis Delta in the Asia-Pacific RegionData presented at the EASL Delta Conference 2010
Le Gal et al Emerg Infect Dis 2006
Prevalence of Hepatitis Delta in Africa
Genotypes 1 5-8
Anti-HDV Prevalence among HBsAg-positive patients in Europe (EK Manesis EASL Special Conference 2010)
Gaeta Rizzetto et al Hepatology 2000
0
5
10
15
20
25
30
0-29 30-49 gt50
1987
1992
1997
Age of Patients
a
nti
-HD
V-p
osi
tive
H
BsA
g+
Decline of anti-HDV Prevalence in Eastern Europe in the 1990rsquos
Older DataHDV Epidemiology in the USA
Highly variable lt1 to 30 among chronic HBV carriers
NHANES IV (CDC 2003-2004)
128 HBsAg+ individuals was anti-HDV+ (36)
Nath et al Am J Epidemiol 1985
Blood Donors 14 Southeast to 12 Pacific region
Weisfuse et al Hepatology 1989
Homosexual Men 2
Rizzetto et al JID 1982 Troisi et al Blood 1993
Haemophiliacs 19 Female Prostitutes 21
Hershow et al Ann Intern Med 1989
Hepatitis B Carriers in Illinois 30
Njei Hepatology 2016
Njei Hepatology 2016
HDV infections in the US population
26 reported past IVdruguse
bull Baltimore (n=194258) prevalence declined from 15 to 11 in IVD between 1988-1989 and 2005-20062
o However among those with CHB prevalence increased to 50
bull US Veterans (n=2175 HBsAg + and tested for HDV) 34positive3
bull NHANES 1999-2012 weighted data 002 prevalence
bull 8 HDV in HBV patients San Francisco (2012)
bull Need for improved surveillance in the US
bull Recent indications that HDV prevalence is increasing
bull HDV prevalence in US was not assessed widely
1
Gish et al 2013 J Gastroenterol Hepatol2Kucirka et al 2010 J Infect Dis
3Kushner et al 2015 J Hepatol4 Njei et al 2016 Hepatol
HDV Epidemiology in the USANorthern California
Journal of Gastroenterology and Hepatology Gish et al 2013
1296 HBsAg positive patients (incomplete data) rarr 82 (63) anti-HDV positive
bull 71 malebull 54 non-hispanic Caucasiansbull 28 asian-pac immigrantsbull 34 anti-HCV positive (with 67 cirrhosis)
499 HBsAg positive patients (complete data) rarr 42 (84) anti-HDV positive
HDV in the US VA
bull 35 of HBsAg+ who where tested were anti-HDV positive
bull Predictors of being HDV tested includedbull male gender (45 vs 13 p lt0001)bull Asian ethnicity (85 vs le5 any other p lt0001)bull HBcIgM+ status (29 vs 90 of HBcIgM- plt0001)bull HBeAg+ (213 vs 130 HBeAg- plt0001)bull HCVAb+ (53 vs 43 HCVAb- plt0001)bull HIV+ (94 vs 40 HIV- plt0001)bull ALT (peak plusmn 180d 383 vs 95ul plt0001)bull HBV DNA gt 2000 IUml (218 vs 147 plt 0001)[
Kushner AASLD 2015 (see notes)
HDV in the US VA (part 2)
bull 74 HDV+ individuals
ndash 43 (58) were HCVAb+
ndash 7 (95) HIV-coinfected
ndash There was no difference in age ethnicity or comorbidity in HDV+ and HDV-subjects
ndash 69 of HDV+ were HBeAg- 74 HBeAb+ and 2326 (88) had HBV DNA titers lt2000 IUml
Kushner AASLD 2015
HDV Epidemiology in the US
Kurcirka et al JID 2010
Participation in the 1st International Quality Control for HDV RNA Quantitation (2013)
Le Gal et al 2016 HepatolHayden HDIN AASLD 2016
Newly Diagnosed HDV Patients in the US(Unique Patients)
4946 4274
4841 5043 5259 5916
6386
7442
9079
-
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
2008 2009 2010 2011 2012 2013 2014 2015 2016Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Chronic HBV Pts and Pts with HDV
00
20
40
60
80
100
120
140
-
10000
20000
30000
40000
50000
60000
2008 2009 2010 2011 2012 2013 2014 2015 2016
o
f C
hro
nic
HB
V P
ts w
ith
HD
V
New
ly D
xC
hro
nic
HB
V P
ts
Newly Dx Chronic HBV Patients (Unique) of Chronic HBV with HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV Tests Ordered and Chronic HBV Patients Tested for HDV
00
10
20
30
40
50
-
1000
2000
3000
4000
5000
200820092010201120122013201420152016 C
hro
nic
HB
V T
este
d f
or
HD
V
HD
V T
ests
Ord
ere
d
HDV Test Claims (CPT 86692) Chronic HBV Tested for HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Top 20 US Geographies for HDV Patients
650
569
429424
351
272
196146145129122122109104090089084084084081
000
100
200
300
400
500
600
700
Bro
okl
yn N
Y
Ch
icag
o I
L
Bro
nx
NY
Co
ron
a N
Y
Hu
nti
ngt
on
hellip
New
Yo
rk N
Y
Jam
aica
NY
Scar
sdal
e N
Y
Ber
wyn
IL
Ph
ilad
elp
hihellip
Pas
saic
NJ
Ho
ust
on
TX
Mia
mi
FL
San
hellip
Hia
leah
FL
Par
kvill
e M
D
Gai
nes
ville
hellip
Ovi
edo
FL
Yon
kers
NY
Hem
pst
ead
hellip
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Comparison of HDV Patient Footprint 2008 vs 2016 and Top 20 Geographies for Each Year
2008 2016
1 Brooklyn NY 6 Bronx NY 11 La Puente CA 16 Chicago IL
2 New York NY 7 Philadelphia PA 12 St Petersburg FL 17 Franklin MA
3 Yonkers NY 8 Jamaica NY 13 Staten Island NY 18 Las Vegas NV
4 Corona NY 9 San Francisco CA 14 Pittsburg CA 19 Newburgh NY
5 Scarsdale NY 10 Passaic NJ 15 Detroit MI 20 Huntington ST NY
1 Chicago IL 6 New York NY 11 Huntington ST NY 16 Cicero IL
2 Berwyn IL 7 Bronx NY 12 Philadelphia PA 17 Parkville MD
3 Brooklyn NY 8 Jamaica NY 13 Houston TX 18 Miami FL
4 Corona NY 9 Lombard NY 14 Passaic NJ 19 Hialeah FL
5 Waukegan IL 10 Aurora IL 15 Staten Island NY 20 Las Vegas NV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
PhoneAudio Option
United States +1 (213) 929-4232
Audio PIN Shown after joining the webinar
Access Code 642-605-645All attendees are muted
Questions Feel free to submit questions in the chat box at anytime throughout the webinar
Questions
Disclosures
bull Dr Robert Gish is a Medical Consultant for Eiger Pharmaceuticals
Epidemiology of Hepatitis DeltaKey messages
An estimated 15-20 Million individuals are infected with HDV worldwide
Hepatitis Delta is the most severe form of chronic viral hepatitisrarr No testing ndash no identification of HDV infection
The clinical manifestations of hepatitis delta differs between regions and has changed during the last 3 decades
Hepatitis Delta is a dynamic disease - Both HBV and HDV contribute to disease progression
Migrant populations and special risks groups show particular high HDV prevalence
The HDV genotype matters
After H Wedemeyer
HDV Significance
bull HDV infection is associated with
ndash Increased liver disease severity in setting of both superinfection and coinfection with HBV
ndash More rapid rates of disease progression and early cirrhosis
Wang-Huei Sheng et al Clin Infect Dis 2007 Apr 144(7)988-95 Epub 2007 Feb 20
ndash Increased risk of HCC (up to 3x fold in HBV-cirrhosis)
Fattovich G Giustina G Christensen E Pantalena M Zagni I Realdi G SchalmSW Influence of hepatitis delta virus infection on morbidity and mortality in compensated cirrhosis type B The European Concerted Action on Viral Hepatitis (Eurohep) Gut 200046420ndash426
HDV Virology
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HDV Transmission requires HBsAg
HDV Epidemiology
Mario Rizzetto Cold Spring Harb Perspect Med 20155a021576
HDV = delta-virus delta-agent Always found in association
with HBV-infection Worldwide infection asymp15-20
million The most common routes of
transmissionndash intravenous transmission (IDU)ndash percutaneous transmission (tattoo
piercing)ndash sexually transmissionndash intrafamilial transmission
Endemic regionsndash Mongoliandash Mediterranean countries (most
often in children and young people)ndash Far East (infectiousness varies from
90 among HBsAg-carriers living in the Pacific Islands up to 5 HBsAg-carriers in Japan)
ndash Amazonia
HDV TESTING RECOMMENDATIONSamong HBsAg+ Individuals
bullAASLD Guidelines ldquoLaboratory tests should include assessment of liver disease markers of HBV replication and tests for coinfection with HCV HDV or HIV in those at riskrdquo which includes all individuals from HDV endemic areas and those with history of IDUrdquo
bullEASL Guidelines ldquoOther causes of chronic liver disease should be systematically looked for including co-infections with HDV HCV andor HIV (A1)rdquo
bullAPASL Guidelines ldquoOther causes of chronic liver disease should be systematically looked for including coinfections with HDVrdquo
Different HDV Genotypes in Different Regions
Wedemeyer amp Manns Nat Rev Gastroenterol 2010
Hughes et al The Lancet 2011 Abbas et al World J Gastroenterol 2012
Prevalence of Hepatitis Delta by Genotype in the Asia-Pacific Region
Country Prevalence Author Poster
No
India 152
109
Raja WA et al
Asim M
82
8
Korea 04 (OLT) Jung Y J et al 47
Pakistan 352
453
400
453
Mumtaz K et al
Zaki M et al
Bhatti TA et al
Memon M S et al
71
7
13
95
Iran 76 Azinmehr L et al 11
Turkey 25 (Izmir)
34 (Izmir)
8 (SE)
9 (Ddiyarbakir)
Koumlse S et al
Akpinar Z et al
Turhanoglu M et al
Gulsun S et al
26
40
41
58
EASL Monothematic Conference Delta Hepatitis 2010
Prevalence of Hepatitis Delta in the Asia-Pacific RegionData presented at the EASL Delta Conference 2010
Le Gal et al Emerg Infect Dis 2006
Prevalence of Hepatitis Delta in Africa
Genotypes 1 5-8
Anti-HDV Prevalence among HBsAg-positive patients in Europe (EK Manesis EASL Special Conference 2010)
Gaeta Rizzetto et al Hepatology 2000
0
5
10
15
20
25
30
0-29 30-49 gt50
1987
1992
1997
Age of Patients
a
nti
-HD
V-p
osi
tive
H
BsA
g+
Decline of anti-HDV Prevalence in Eastern Europe in the 1990rsquos
Older DataHDV Epidemiology in the USA
Highly variable lt1 to 30 among chronic HBV carriers
NHANES IV (CDC 2003-2004)
128 HBsAg+ individuals was anti-HDV+ (36)
Nath et al Am J Epidemiol 1985
Blood Donors 14 Southeast to 12 Pacific region
Weisfuse et al Hepatology 1989
Homosexual Men 2
Rizzetto et al JID 1982 Troisi et al Blood 1993
Haemophiliacs 19 Female Prostitutes 21
Hershow et al Ann Intern Med 1989
Hepatitis B Carriers in Illinois 30
Njei Hepatology 2016
Njei Hepatology 2016
HDV infections in the US population
26 reported past IVdruguse
bull Baltimore (n=194258) prevalence declined from 15 to 11 in IVD between 1988-1989 and 2005-20062
o However among those with CHB prevalence increased to 50
bull US Veterans (n=2175 HBsAg + and tested for HDV) 34positive3
bull NHANES 1999-2012 weighted data 002 prevalence
bull 8 HDV in HBV patients San Francisco (2012)
bull Need for improved surveillance in the US
bull Recent indications that HDV prevalence is increasing
bull HDV prevalence in US was not assessed widely
1
Gish et al 2013 J Gastroenterol Hepatol2Kucirka et al 2010 J Infect Dis
3Kushner et al 2015 J Hepatol4 Njei et al 2016 Hepatol
HDV Epidemiology in the USANorthern California
Journal of Gastroenterology and Hepatology Gish et al 2013
1296 HBsAg positive patients (incomplete data) rarr 82 (63) anti-HDV positive
bull 71 malebull 54 non-hispanic Caucasiansbull 28 asian-pac immigrantsbull 34 anti-HCV positive (with 67 cirrhosis)
499 HBsAg positive patients (complete data) rarr 42 (84) anti-HDV positive
HDV in the US VA
bull 35 of HBsAg+ who where tested were anti-HDV positive
bull Predictors of being HDV tested includedbull male gender (45 vs 13 p lt0001)bull Asian ethnicity (85 vs le5 any other p lt0001)bull HBcIgM+ status (29 vs 90 of HBcIgM- plt0001)bull HBeAg+ (213 vs 130 HBeAg- plt0001)bull HCVAb+ (53 vs 43 HCVAb- plt0001)bull HIV+ (94 vs 40 HIV- plt0001)bull ALT (peak plusmn 180d 383 vs 95ul plt0001)bull HBV DNA gt 2000 IUml (218 vs 147 plt 0001)[
Kushner AASLD 2015 (see notes)
HDV in the US VA (part 2)
bull 74 HDV+ individuals
ndash 43 (58) were HCVAb+
ndash 7 (95) HIV-coinfected
ndash There was no difference in age ethnicity or comorbidity in HDV+ and HDV-subjects
ndash 69 of HDV+ were HBeAg- 74 HBeAb+ and 2326 (88) had HBV DNA titers lt2000 IUml
Kushner AASLD 2015
HDV Epidemiology in the US
Kurcirka et al JID 2010
Participation in the 1st International Quality Control for HDV RNA Quantitation (2013)
Le Gal et al 2016 HepatolHayden HDIN AASLD 2016
Newly Diagnosed HDV Patients in the US(Unique Patients)
4946 4274
4841 5043 5259 5916
6386
7442
9079
-
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
2008 2009 2010 2011 2012 2013 2014 2015 2016Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Chronic HBV Pts and Pts with HDV
00
20
40
60
80
100
120
140
-
10000
20000
30000
40000
50000
60000
2008 2009 2010 2011 2012 2013 2014 2015 2016
o
f C
hro
nic
HB
V P
ts w
ith
HD
V
New
ly D
xC
hro
nic
HB
V P
ts
Newly Dx Chronic HBV Patients (Unique) of Chronic HBV with HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV Tests Ordered and Chronic HBV Patients Tested for HDV
00
10
20
30
40
50
-
1000
2000
3000
4000
5000
200820092010201120122013201420152016 C
hro
nic
HB
V T
este
d f
or
HD
V
HD
V T
ests
Ord
ere
d
HDV Test Claims (CPT 86692) Chronic HBV Tested for HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Top 20 US Geographies for HDV Patients
650
569
429424
351
272
196146145129122122109104090089084084084081
000
100
200
300
400
500
600
700
Bro
okl
yn N
Y
Ch
icag
o I
L
Bro
nx
NY
Co
ron
a N
Y
Hu
nti
ngt
on
hellip
New
Yo
rk N
Y
Jam
aica
NY
Scar
sdal
e N
Y
Ber
wyn
IL
Ph
ilad
elp
hihellip
Pas
saic
NJ
Ho
ust
on
TX
Mia
mi
FL
San
hellip
Hia
leah
FL
Par
kvill
e M
D
Gai
nes
ville
hellip
Ovi
edo
FL
Yon
kers
NY
Hem
pst
ead
hellip
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Comparison of HDV Patient Footprint 2008 vs 2016 and Top 20 Geographies for Each Year
2008 2016
1 Brooklyn NY 6 Bronx NY 11 La Puente CA 16 Chicago IL
2 New York NY 7 Philadelphia PA 12 St Petersburg FL 17 Franklin MA
3 Yonkers NY 8 Jamaica NY 13 Staten Island NY 18 Las Vegas NV
4 Corona NY 9 San Francisco CA 14 Pittsburg CA 19 Newburgh NY
5 Scarsdale NY 10 Passaic NJ 15 Detroit MI 20 Huntington ST NY
1 Chicago IL 6 New York NY 11 Huntington ST NY 16 Cicero IL
2 Berwyn IL 7 Bronx NY 12 Philadelphia PA 17 Parkville MD
3 Brooklyn NY 8 Jamaica NY 13 Houston TX 18 Miami FL
4 Corona NY 9 Lombard NY 14 Passaic NJ 19 Hialeah FL
5 Waukegan IL 10 Aurora IL 15 Staten Island NY 20 Las Vegas NV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Questions Feel free to submit questions in the chat box at anytime throughout the webinar
Questions
Disclosures
bull Dr Robert Gish is a Medical Consultant for Eiger Pharmaceuticals
Epidemiology of Hepatitis DeltaKey messages
An estimated 15-20 Million individuals are infected with HDV worldwide
Hepatitis Delta is the most severe form of chronic viral hepatitisrarr No testing ndash no identification of HDV infection
The clinical manifestations of hepatitis delta differs between regions and has changed during the last 3 decades
Hepatitis Delta is a dynamic disease - Both HBV and HDV contribute to disease progression
Migrant populations and special risks groups show particular high HDV prevalence
The HDV genotype matters
After H Wedemeyer
HDV Significance
bull HDV infection is associated with
ndash Increased liver disease severity in setting of both superinfection and coinfection with HBV
ndash More rapid rates of disease progression and early cirrhosis
Wang-Huei Sheng et al Clin Infect Dis 2007 Apr 144(7)988-95 Epub 2007 Feb 20
ndash Increased risk of HCC (up to 3x fold in HBV-cirrhosis)
Fattovich G Giustina G Christensen E Pantalena M Zagni I Realdi G SchalmSW Influence of hepatitis delta virus infection on morbidity and mortality in compensated cirrhosis type B The European Concerted Action on Viral Hepatitis (Eurohep) Gut 200046420ndash426
HDV Virology
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HDV Transmission requires HBsAg
HDV Epidemiology
Mario Rizzetto Cold Spring Harb Perspect Med 20155a021576
HDV = delta-virus delta-agent Always found in association
with HBV-infection Worldwide infection asymp15-20
million The most common routes of
transmissionndash intravenous transmission (IDU)ndash percutaneous transmission (tattoo
piercing)ndash sexually transmissionndash intrafamilial transmission
Endemic regionsndash Mongoliandash Mediterranean countries (most
often in children and young people)ndash Far East (infectiousness varies from
90 among HBsAg-carriers living in the Pacific Islands up to 5 HBsAg-carriers in Japan)
ndash Amazonia
HDV TESTING RECOMMENDATIONSamong HBsAg+ Individuals
bullAASLD Guidelines ldquoLaboratory tests should include assessment of liver disease markers of HBV replication and tests for coinfection with HCV HDV or HIV in those at riskrdquo which includes all individuals from HDV endemic areas and those with history of IDUrdquo
bullEASL Guidelines ldquoOther causes of chronic liver disease should be systematically looked for including co-infections with HDV HCV andor HIV (A1)rdquo
bullAPASL Guidelines ldquoOther causes of chronic liver disease should be systematically looked for including coinfections with HDVrdquo
Different HDV Genotypes in Different Regions
Wedemeyer amp Manns Nat Rev Gastroenterol 2010
Hughes et al The Lancet 2011 Abbas et al World J Gastroenterol 2012
Prevalence of Hepatitis Delta by Genotype in the Asia-Pacific Region
Country Prevalence Author Poster
No
India 152
109
Raja WA et al
Asim M
82
8
Korea 04 (OLT) Jung Y J et al 47
Pakistan 352
453
400
453
Mumtaz K et al
Zaki M et al
Bhatti TA et al
Memon M S et al
71
7
13
95
Iran 76 Azinmehr L et al 11
Turkey 25 (Izmir)
34 (Izmir)
8 (SE)
9 (Ddiyarbakir)
Koumlse S et al
Akpinar Z et al
Turhanoglu M et al
Gulsun S et al
26
40
41
58
EASL Monothematic Conference Delta Hepatitis 2010
Prevalence of Hepatitis Delta in the Asia-Pacific RegionData presented at the EASL Delta Conference 2010
Le Gal et al Emerg Infect Dis 2006
Prevalence of Hepatitis Delta in Africa
Genotypes 1 5-8
Anti-HDV Prevalence among HBsAg-positive patients in Europe (EK Manesis EASL Special Conference 2010)
Gaeta Rizzetto et al Hepatology 2000
0
5
10
15
20
25
30
0-29 30-49 gt50
1987
1992
1997
Age of Patients
a
nti
-HD
V-p
osi
tive
H
BsA
g+
Decline of anti-HDV Prevalence in Eastern Europe in the 1990rsquos
Older DataHDV Epidemiology in the USA
Highly variable lt1 to 30 among chronic HBV carriers
NHANES IV (CDC 2003-2004)
128 HBsAg+ individuals was anti-HDV+ (36)
Nath et al Am J Epidemiol 1985
Blood Donors 14 Southeast to 12 Pacific region
Weisfuse et al Hepatology 1989
Homosexual Men 2
Rizzetto et al JID 1982 Troisi et al Blood 1993
Haemophiliacs 19 Female Prostitutes 21
Hershow et al Ann Intern Med 1989
Hepatitis B Carriers in Illinois 30
Njei Hepatology 2016
Njei Hepatology 2016
HDV infections in the US population
26 reported past IVdruguse
bull Baltimore (n=194258) prevalence declined from 15 to 11 in IVD between 1988-1989 and 2005-20062
o However among those with CHB prevalence increased to 50
bull US Veterans (n=2175 HBsAg + and tested for HDV) 34positive3
bull NHANES 1999-2012 weighted data 002 prevalence
bull 8 HDV in HBV patients San Francisco (2012)
bull Need for improved surveillance in the US
bull Recent indications that HDV prevalence is increasing
bull HDV prevalence in US was not assessed widely
1
Gish et al 2013 J Gastroenterol Hepatol2Kucirka et al 2010 J Infect Dis
3Kushner et al 2015 J Hepatol4 Njei et al 2016 Hepatol
HDV Epidemiology in the USANorthern California
Journal of Gastroenterology and Hepatology Gish et al 2013
1296 HBsAg positive patients (incomplete data) rarr 82 (63) anti-HDV positive
bull 71 malebull 54 non-hispanic Caucasiansbull 28 asian-pac immigrantsbull 34 anti-HCV positive (with 67 cirrhosis)
499 HBsAg positive patients (complete data) rarr 42 (84) anti-HDV positive
HDV in the US VA
bull 35 of HBsAg+ who where tested were anti-HDV positive
bull Predictors of being HDV tested includedbull male gender (45 vs 13 p lt0001)bull Asian ethnicity (85 vs le5 any other p lt0001)bull HBcIgM+ status (29 vs 90 of HBcIgM- plt0001)bull HBeAg+ (213 vs 130 HBeAg- plt0001)bull HCVAb+ (53 vs 43 HCVAb- plt0001)bull HIV+ (94 vs 40 HIV- plt0001)bull ALT (peak plusmn 180d 383 vs 95ul plt0001)bull HBV DNA gt 2000 IUml (218 vs 147 plt 0001)[
Kushner AASLD 2015 (see notes)
HDV in the US VA (part 2)
bull 74 HDV+ individuals
ndash 43 (58) were HCVAb+
ndash 7 (95) HIV-coinfected
ndash There was no difference in age ethnicity or comorbidity in HDV+ and HDV-subjects
ndash 69 of HDV+ were HBeAg- 74 HBeAb+ and 2326 (88) had HBV DNA titers lt2000 IUml
Kushner AASLD 2015
HDV Epidemiology in the US
Kurcirka et al JID 2010
Participation in the 1st International Quality Control for HDV RNA Quantitation (2013)
Le Gal et al 2016 HepatolHayden HDIN AASLD 2016
Newly Diagnosed HDV Patients in the US(Unique Patients)
4946 4274
4841 5043 5259 5916
6386
7442
9079
-
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
2008 2009 2010 2011 2012 2013 2014 2015 2016Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Chronic HBV Pts and Pts with HDV
00
20
40
60
80
100
120
140
-
10000
20000
30000
40000
50000
60000
2008 2009 2010 2011 2012 2013 2014 2015 2016
o
f C
hro
nic
HB
V P
ts w
ith
HD
V
New
ly D
xC
hro
nic
HB
V P
ts
Newly Dx Chronic HBV Patients (Unique) of Chronic HBV with HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV Tests Ordered and Chronic HBV Patients Tested for HDV
00
10
20
30
40
50
-
1000
2000
3000
4000
5000
200820092010201120122013201420152016 C
hro
nic
HB
V T
este
d f
or
HD
V
HD
V T
ests
Ord
ere
d
HDV Test Claims (CPT 86692) Chronic HBV Tested for HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Top 20 US Geographies for HDV Patients
650
569
429424
351
272
196146145129122122109104090089084084084081
000
100
200
300
400
500
600
700
Bro
okl
yn N
Y
Ch
icag
o I
L
Bro
nx
NY
Co
ron
a N
Y
Hu
nti
ngt
on
hellip
New
Yo
rk N
Y
Jam
aica
NY
Scar
sdal
e N
Y
Ber
wyn
IL
Ph
ilad
elp
hihellip
Pas
saic
NJ
Ho
ust
on
TX
Mia
mi
FL
San
hellip
Hia
leah
FL
Par
kvill
e M
D
Gai
nes
ville
hellip
Ovi
edo
FL
Yon
kers
NY
Hem
pst
ead
hellip
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Comparison of HDV Patient Footprint 2008 vs 2016 and Top 20 Geographies for Each Year
2008 2016
1 Brooklyn NY 6 Bronx NY 11 La Puente CA 16 Chicago IL
2 New York NY 7 Philadelphia PA 12 St Petersburg FL 17 Franklin MA
3 Yonkers NY 8 Jamaica NY 13 Staten Island NY 18 Las Vegas NV
4 Corona NY 9 San Francisco CA 14 Pittsburg CA 19 Newburgh NY
5 Scarsdale NY 10 Passaic NJ 15 Detroit MI 20 Huntington ST NY
1 Chicago IL 6 New York NY 11 Huntington ST NY 16 Cicero IL
2 Berwyn IL 7 Bronx NY 12 Philadelphia PA 17 Parkville MD
3 Brooklyn NY 8 Jamaica NY 13 Houston TX 18 Miami FL
4 Corona NY 9 Lombard NY 14 Passaic NJ 19 Hialeah FL
5 Waukegan IL 10 Aurora IL 15 Staten Island NY 20 Las Vegas NV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Disclosures
bull Dr Robert Gish is a Medical Consultant for Eiger Pharmaceuticals
Epidemiology of Hepatitis DeltaKey messages
An estimated 15-20 Million individuals are infected with HDV worldwide
Hepatitis Delta is the most severe form of chronic viral hepatitisrarr No testing ndash no identification of HDV infection
The clinical manifestations of hepatitis delta differs between regions and has changed during the last 3 decades
Hepatitis Delta is a dynamic disease - Both HBV and HDV contribute to disease progression
Migrant populations and special risks groups show particular high HDV prevalence
The HDV genotype matters
After H Wedemeyer
HDV Significance
bull HDV infection is associated with
ndash Increased liver disease severity in setting of both superinfection and coinfection with HBV
ndash More rapid rates of disease progression and early cirrhosis
Wang-Huei Sheng et al Clin Infect Dis 2007 Apr 144(7)988-95 Epub 2007 Feb 20
ndash Increased risk of HCC (up to 3x fold in HBV-cirrhosis)
Fattovich G Giustina G Christensen E Pantalena M Zagni I Realdi G SchalmSW Influence of hepatitis delta virus infection on morbidity and mortality in compensated cirrhosis type B The European Concerted Action on Viral Hepatitis (Eurohep) Gut 200046420ndash426
HDV Virology
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HDV Transmission requires HBsAg
HDV Epidemiology
Mario Rizzetto Cold Spring Harb Perspect Med 20155a021576
HDV = delta-virus delta-agent Always found in association
with HBV-infection Worldwide infection asymp15-20
million The most common routes of
transmissionndash intravenous transmission (IDU)ndash percutaneous transmission (tattoo
piercing)ndash sexually transmissionndash intrafamilial transmission
Endemic regionsndash Mongoliandash Mediterranean countries (most
often in children and young people)ndash Far East (infectiousness varies from
90 among HBsAg-carriers living in the Pacific Islands up to 5 HBsAg-carriers in Japan)
ndash Amazonia
HDV TESTING RECOMMENDATIONSamong HBsAg+ Individuals
bullAASLD Guidelines ldquoLaboratory tests should include assessment of liver disease markers of HBV replication and tests for coinfection with HCV HDV or HIV in those at riskrdquo which includes all individuals from HDV endemic areas and those with history of IDUrdquo
bullEASL Guidelines ldquoOther causes of chronic liver disease should be systematically looked for including co-infections with HDV HCV andor HIV (A1)rdquo
bullAPASL Guidelines ldquoOther causes of chronic liver disease should be systematically looked for including coinfections with HDVrdquo
Different HDV Genotypes in Different Regions
Wedemeyer amp Manns Nat Rev Gastroenterol 2010
Hughes et al The Lancet 2011 Abbas et al World J Gastroenterol 2012
Prevalence of Hepatitis Delta by Genotype in the Asia-Pacific Region
Country Prevalence Author Poster
No
India 152
109
Raja WA et al
Asim M
82
8
Korea 04 (OLT) Jung Y J et al 47
Pakistan 352
453
400
453
Mumtaz K et al
Zaki M et al
Bhatti TA et al
Memon M S et al
71
7
13
95
Iran 76 Azinmehr L et al 11
Turkey 25 (Izmir)
34 (Izmir)
8 (SE)
9 (Ddiyarbakir)
Koumlse S et al
Akpinar Z et al
Turhanoglu M et al
Gulsun S et al
26
40
41
58
EASL Monothematic Conference Delta Hepatitis 2010
Prevalence of Hepatitis Delta in the Asia-Pacific RegionData presented at the EASL Delta Conference 2010
Le Gal et al Emerg Infect Dis 2006
Prevalence of Hepatitis Delta in Africa
Genotypes 1 5-8
Anti-HDV Prevalence among HBsAg-positive patients in Europe (EK Manesis EASL Special Conference 2010)
Gaeta Rizzetto et al Hepatology 2000
0
5
10
15
20
25
30
0-29 30-49 gt50
1987
1992
1997
Age of Patients
a
nti
-HD
V-p
osi
tive
H
BsA
g+
Decline of anti-HDV Prevalence in Eastern Europe in the 1990rsquos
Older DataHDV Epidemiology in the USA
Highly variable lt1 to 30 among chronic HBV carriers
NHANES IV (CDC 2003-2004)
128 HBsAg+ individuals was anti-HDV+ (36)
Nath et al Am J Epidemiol 1985
Blood Donors 14 Southeast to 12 Pacific region
Weisfuse et al Hepatology 1989
Homosexual Men 2
Rizzetto et al JID 1982 Troisi et al Blood 1993
Haemophiliacs 19 Female Prostitutes 21
Hershow et al Ann Intern Med 1989
Hepatitis B Carriers in Illinois 30
Njei Hepatology 2016
Njei Hepatology 2016
HDV infections in the US population
26 reported past IVdruguse
bull Baltimore (n=194258) prevalence declined from 15 to 11 in IVD between 1988-1989 and 2005-20062
o However among those with CHB prevalence increased to 50
bull US Veterans (n=2175 HBsAg + and tested for HDV) 34positive3
bull NHANES 1999-2012 weighted data 002 prevalence
bull 8 HDV in HBV patients San Francisco (2012)
bull Need for improved surveillance in the US
bull Recent indications that HDV prevalence is increasing
bull HDV prevalence in US was not assessed widely
1
Gish et al 2013 J Gastroenterol Hepatol2Kucirka et al 2010 J Infect Dis
3Kushner et al 2015 J Hepatol4 Njei et al 2016 Hepatol
HDV Epidemiology in the USANorthern California
Journal of Gastroenterology and Hepatology Gish et al 2013
1296 HBsAg positive patients (incomplete data) rarr 82 (63) anti-HDV positive
bull 71 malebull 54 non-hispanic Caucasiansbull 28 asian-pac immigrantsbull 34 anti-HCV positive (with 67 cirrhosis)
499 HBsAg positive patients (complete data) rarr 42 (84) anti-HDV positive
HDV in the US VA
bull 35 of HBsAg+ who where tested were anti-HDV positive
bull Predictors of being HDV tested includedbull male gender (45 vs 13 p lt0001)bull Asian ethnicity (85 vs le5 any other p lt0001)bull HBcIgM+ status (29 vs 90 of HBcIgM- plt0001)bull HBeAg+ (213 vs 130 HBeAg- plt0001)bull HCVAb+ (53 vs 43 HCVAb- plt0001)bull HIV+ (94 vs 40 HIV- plt0001)bull ALT (peak plusmn 180d 383 vs 95ul plt0001)bull HBV DNA gt 2000 IUml (218 vs 147 plt 0001)[
Kushner AASLD 2015 (see notes)
HDV in the US VA (part 2)
bull 74 HDV+ individuals
ndash 43 (58) were HCVAb+
ndash 7 (95) HIV-coinfected
ndash There was no difference in age ethnicity or comorbidity in HDV+ and HDV-subjects
ndash 69 of HDV+ were HBeAg- 74 HBeAb+ and 2326 (88) had HBV DNA titers lt2000 IUml
Kushner AASLD 2015
HDV Epidemiology in the US
Kurcirka et al JID 2010
Participation in the 1st International Quality Control for HDV RNA Quantitation (2013)
Le Gal et al 2016 HepatolHayden HDIN AASLD 2016
Newly Diagnosed HDV Patients in the US(Unique Patients)
4946 4274
4841 5043 5259 5916
6386
7442
9079
-
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
2008 2009 2010 2011 2012 2013 2014 2015 2016Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Chronic HBV Pts and Pts with HDV
00
20
40
60
80
100
120
140
-
10000
20000
30000
40000
50000
60000
2008 2009 2010 2011 2012 2013 2014 2015 2016
o
f C
hro
nic
HB
V P
ts w
ith
HD
V
New
ly D
xC
hro
nic
HB
V P
ts
Newly Dx Chronic HBV Patients (Unique) of Chronic HBV with HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV Tests Ordered and Chronic HBV Patients Tested for HDV
00
10
20
30
40
50
-
1000
2000
3000
4000
5000
200820092010201120122013201420152016 C
hro
nic
HB
V T
este
d f
or
HD
V
HD
V T
ests
Ord
ere
d
HDV Test Claims (CPT 86692) Chronic HBV Tested for HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Top 20 US Geographies for HDV Patients
650
569
429424
351
272
196146145129122122109104090089084084084081
000
100
200
300
400
500
600
700
Bro
okl
yn N
Y
Ch
icag
o I
L
Bro
nx
NY
Co
ron
a N
Y
Hu
nti
ngt
on
hellip
New
Yo
rk N
Y
Jam
aica
NY
Scar
sdal
e N
Y
Ber
wyn
IL
Ph
ilad
elp
hihellip
Pas
saic
NJ
Ho
ust
on
TX
Mia
mi
FL
San
hellip
Hia
leah
FL
Par
kvill
e M
D
Gai
nes
ville
hellip
Ovi
edo
FL
Yon
kers
NY
Hem
pst
ead
hellip
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Comparison of HDV Patient Footprint 2008 vs 2016 and Top 20 Geographies for Each Year
2008 2016
1 Brooklyn NY 6 Bronx NY 11 La Puente CA 16 Chicago IL
2 New York NY 7 Philadelphia PA 12 St Petersburg FL 17 Franklin MA
3 Yonkers NY 8 Jamaica NY 13 Staten Island NY 18 Las Vegas NV
4 Corona NY 9 San Francisco CA 14 Pittsburg CA 19 Newburgh NY
5 Scarsdale NY 10 Passaic NJ 15 Detroit MI 20 Huntington ST NY
1 Chicago IL 6 New York NY 11 Huntington ST NY 16 Cicero IL
2 Berwyn IL 7 Bronx NY 12 Philadelphia PA 17 Parkville MD
3 Brooklyn NY 8 Jamaica NY 13 Houston TX 18 Miami FL
4 Corona NY 9 Lombard NY 14 Passaic NJ 19 Hialeah FL
5 Waukegan IL 10 Aurora IL 15 Staten Island NY 20 Las Vegas NV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Epidemiology of Hepatitis DeltaKey messages
An estimated 15-20 Million individuals are infected with HDV worldwide
Hepatitis Delta is the most severe form of chronic viral hepatitisrarr No testing ndash no identification of HDV infection
The clinical manifestations of hepatitis delta differs between regions and has changed during the last 3 decades
Hepatitis Delta is a dynamic disease - Both HBV and HDV contribute to disease progression
Migrant populations and special risks groups show particular high HDV prevalence
The HDV genotype matters
After H Wedemeyer
HDV Significance
bull HDV infection is associated with
ndash Increased liver disease severity in setting of both superinfection and coinfection with HBV
ndash More rapid rates of disease progression and early cirrhosis
Wang-Huei Sheng et al Clin Infect Dis 2007 Apr 144(7)988-95 Epub 2007 Feb 20
ndash Increased risk of HCC (up to 3x fold in HBV-cirrhosis)
Fattovich G Giustina G Christensen E Pantalena M Zagni I Realdi G SchalmSW Influence of hepatitis delta virus infection on morbidity and mortality in compensated cirrhosis type B The European Concerted Action on Viral Hepatitis (Eurohep) Gut 200046420ndash426
HDV Virology
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HDV Transmission requires HBsAg
HDV Epidemiology
Mario Rizzetto Cold Spring Harb Perspect Med 20155a021576
HDV = delta-virus delta-agent Always found in association
with HBV-infection Worldwide infection asymp15-20
million The most common routes of
transmissionndash intravenous transmission (IDU)ndash percutaneous transmission (tattoo
piercing)ndash sexually transmissionndash intrafamilial transmission
Endemic regionsndash Mongoliandash Mediterranean countries (most
often in children and young people)ndash Far East (infectiousness varies from
90 among HBsAg-carriers living in the Pacific Islands up to 5 HBsAg-carriers in Japan)
ndash Amazonia
HDV TESTING RECOMMENDATIONSamong HBsAg+ Individuals
bullAASLD Guidelines ldquoLaboratory tests should include assessment of liver disease markers of HBV replication and tests for coinfection with HCV HDV or HIV in those at riskrdquo which includes all individuals from HDV endemic areas and those with history of IDUrdquo
bullEASL Guidelines ldquoOther causes of chronic liver disease should be systematically looked for including co-infections with HDV HCV andor HIV (A1)rdquo
bullAPASL Guidelines ldquoOther causes of chronic liver disease should be systematically looked for including coinfections with HDVrdquo
Different HDV Genotypes in Different Regions
Wedemeyer amp Manns Nat Rev Gastroenterol 2010
Hughes et al The Lancet 2011 Abbas et al World J Gastroenterol 2012
Prevalence of Hepatitis Delta by Genotype in the Asia-Pacific Region
Country Prevalence Author Poster
No
India 152
109
Raja WA et al
Asim M
82
8
Korea 04 (OLT) Jung Y J et al 47
Pakistan 352
453
400
453
Mumtaz K et al
Zaki M et al
Bhatti TA et al
Memon M S et al
71
7
13
95
Iran 76 Azinmehr L et al 11
Turkey 25 (Izmir)
34 (Izmir)
8 (SE)
9 (Ddiyarbakir)
Koumlse S et al
Akpinar Z et al
Turhanoglu M et al
Gulsun S et al
26
40
41
58
EASL Monothematic Conference Delta Hepatitis 2010
Prevalence of Hepatitis Delta in the Asia-Pacific RegionData presented at the EASL Delta Conference 2010
Le Gal et al Emerg Infect Dis 2006
Prevalence of Hepatitis Delta in Africa
Genotypes 1 5-8
Anti-HDV Prevalence among HBsAg-positive patients in Europe (EK Manesis EASL Special Conference 2010)
Gaeta Rizzetto et al Hepatology 2000
0
5
10
15
20
25
30
0-29 30-49 gt50
1987
1992
1997
Age of Patients
a
nti
-HD
V-p
osi
tive
H
BsA
g+
Decline of anti-HDV Prevalence in Eastern Europe in the 1990rsquos
Older DataHDV Epidemiology in the USA
Highly variable lt1 to 30 among chronic HBV carriers
NHANES IV (CDC 2003-2004)
128 HBsAg+ individuals was anti-HDV+ (36)
Nath et al Am J Epidemiol 1985
Blood Donors 14 Southeast to 12 Pacific region
Weisfuse et al Hepatology 1989
Homosexual Men 2
Rizzetto et al JID 1982 Troisi et al Blood 1993
Haemophiliacs 19 Female Prostitutes 21
Hershow et al Ann Intern Med 1989
Hepatitis B Carriers in Illinois 30
Njei Hepatology 2016
Njei Hepatology 2016
HDV infections in the US population
26 reported past IVdruguse
bull Baltimore (n=194258) prevalence declined from 15 to 11 in IVD between 1988-1989 and 2005-20062
o However among those with CHB prevalence increased to 50
bull US Veterans (n=2175 HBsAg + and tested for HDV) 34positive3
bull NHANES 1999-2012 weighted data 002 prevalence
bull 8 HDV in HBV patients San Francisco (2012)
bull Need for improved surveillance in the US
bull Recent indications that HDV prevalence is increasing
bull HDV prevalence in US was not assessed widely
1
Gish et al 2013 J Gastroenterol Hepatol2Kucirka et al 2010 J Infect Dis
3Kushner et al 2015 J Hepatol4 Njei et al 2016 Hepatol
HDV Epidemiology in the USANorthern California
Journal of Gastroenterology and Hepatology Gish et al 2013
1296 HBsAg positive patients (incomplete data) rarr 82 (63) anti-HDV positive
bull 71 malebull 54 non-hispanic Caucasiansbull 28 asian-pac immigrantsbull 34 anti-HCV positive (with 67 cirrhosis)
499 HBsAg positive patients (complete data) rarr 42 (84) anti-HDV positive
HDV in the US VA
bull 35 of HBsAg+ who where tested were anti-HDV positive
bull Predictors of being HDV tested includedbull male gender (45 vs 13 p lt0001)bull Asian ethnicity (85 vs le5 any other p lt0001)bull HBcIgM+ status (29 vs 90 of HBcIgM- plt0001)bull HBeAg+ (213 vs 130 HBeAg- plt0001)bull HCVAb+ (53 vs 43 HCVAb- plt0001)bull HIV+ (94 vs 40 HIV- plt0001)bull ALT (peak plusmn 180d 383 vs 95ul plt0001)bull HBV DNA gt 2000 IUml (218 vs 147 plt 0001)[
Kushner AASLD 2015 (see notes)
HDV in the US VA (part 2)
bull 74 HDV+ individuals
ndash 43 (58) were HCVAb+
ndash 7 (95) HIV-coinfected
ndash There was no difference in age ethnicity or comorbidity in HDV+ and HDV-subjects
ndash 69 of HDV+ were HBeAg- 74 HBeAb+ and 2326 (88) had HBV DNA titers lt2000 IUml
Kushner AASLD 2015
HDV Epidemiology in the US
Kurcirka et al JID 2010
Participation in the 1st International Quality Control for HDV RNA Quantitation (2013)
Le Gal et al 2016 HepatolHayden HDIN AASLD 2016
Newly Diagnosed HDV Patients in the US(Unique Patients)
4946 4274
4841 5043 5259 5916
6386
7442
9079
-
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
2008 2009 2010 2011 2012 2013 2014 2015 2016Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Chronic HBV Pts and Pts with HDV
00
20
40
60
80
100
120
140
-
10000
20000
30000
40000
50000
60000
2008 2009 2010 2011 2012 2013 2014 2015 2016
o
f C
hro
nic
HB
V P
ts w
ith
HD
V
New
ly D
xC
hro
nic
HB
V P
ts
Newly Dx Chronic HBV Patients (Unique) of Chronic HBV with HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV Tests Ordered and Chronic HBV Patients Tested for HDV
00
10
20
30
40
50
-
1000
2000
3000
4000
5000
200820092010201120122013201420152016 C
hro
nic
HB
V T
este
d f
or
HD
V
HD
V T
ests
Ord
ere
d
HDV Test Claims (CPT 86692) Chronic HBV Tested for HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Top 20 US Geographies for HDV Patients
650
569
429424
351
272
196146145129122122109104090089084084084081
000
100
200
300
400
500
600
700
Bro
okl
yn N
Y
Ch
icag
o I
L
Bro
nx
NY
Co
ron
a N
Y
Hu
nti
ngt
on
hellip
New
Yo
rk N
Y
Jam
aica
NY
Scar
sdal
e N
Y
Ber
wyn
IL
Ph
ilad
elp
hihellip
Pas
saic
NJ
Ho
ust
on
TX
Mia
mi
FL
San
hellip
Hia
leah
FL
Par
kvill
e M
D
Gai
nes
ville
hellip
Ovi
edo
FL
Yon
kers
NY
Hem
pst
ead
hellip
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Comparison of HDV Patient Footprint 2008 vs 2016 and Top 20 Geographies for Each Year
2008 2016
1 Brooklyn NY 6 Bronx NY 11 La Puente CA 16 Chicago IL
2 New York NY 7 Philadelphia PA 12 St Petersburg FL 17 Franklin MA
3 Yonkers NY 8 Jamaica NY 13 Staten Island NY 18 Las Vegas NV
4 Corona NY 9 San Francisco CA 14 Pittsburg CA 19 Newburgh NY
5 Scarsdale NY 10 Passaic NJ 15 Detroit MI 20 Huntington ST NY
1 Chicago IL 6 New York NY 11 Huntington ST NY 16 Cicero IL
2 Berwyn IL 7 Bronx NY 12 Philadelphia PA 17 Parkville MD
3 Brooklyn NY 8 Jamaica NY 13 Houston TX 18 Miami FL
4 Corona NY 9 Lombard NY 14 Passaic NJ 19 Hialeah FL
5 Waukegan IL 10 Aurora IL 15 Staten Island NY 20 Las Vegas NV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDV Significance
bull HDV infection is associated with
ndash Increased liver disease severity in setting of both superinfection and coinfection with HBV
ndash More rapid rates of disease progression and early cirrhosis
Wang-Huei Sheng et al Clin Infect Dis 2007 Apr 144(7)988-95 Epub 2007 Feb 20
ndash Increased risk of HCC (up to 3x fold in HBV-cirrhosis)
Fattovich G Giustina G Christensen E Pantalena M Zagni I Realdi G SchalmSW Influence of hepatitis delta virus infection on morbidity and mortality in compensated cirrhosis type B The European Concerted Action on Viral Hepatitis (Eurohep) Gut 200046420ndash426
HDV Virology
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HDV Transmission requires HBsAg
HDV Epidemiology
Mario Rizzetto Cold Spring Harb Perspect Med 20155a021576
HDV = delta-virus delta-agent Always found in association
with HBV-infection Worldwide infection asymp15-20
million The most common routes of
transmissionndash intravenous transmission (IDU)ndash percutaneous transmission (tattoo
piercing)ndash sexually transmissionndash intrafamilial transmission
Endemic regionsndash Mongoliandash Mediterranean countries (most
often in children and young people)ndash Far East (infectiousness varies from
90 among HBsAg-carriers living in the Pacific Islands up to 5 HBsAg-carriers in Japan)
ndash Amazonia
HDV TESTING RECOMMENDATIONSamong HBsAg+ Individuals
bullAASLD Guidelines ldquoLaboratory tests should include assessment of liver disease markers of HBV replication and tests for coinfection with HCV HDV or HIV in those at riskrdquo which includes all individuals from HDV endemic areas and those with history of IDUrdquo
bullEASL Guidelines ldquoOther causes of chronic liver disease should be systematically looked for including co-infections with HDV HCV andor HIV (A1)rdquo
bullAPASL Guidelines ldquoOther causes of chronic liver disease should be systematically looked for including coinfections with HDVrdquo
Different HDV Genotypes in Different Regions
Wedemeyer amp Manns Nat Rev Gastroenterol 2010
Hughes et al The Lancet 2011 Abbas et al World J Gastroenterol 2012
Prevalence of Hepatitis Delta by Genotype in the Asia-Pacific Region
Country Prevalence Author Poster
No
India 152
109
Raja WA et al
Asim M
82
8
Korea 04 (OLT) Jung Y J et al 47
Pakistan 352
453
400
453
Mumtaz K et al
Zaki M et al
Bhatti TA et al
Memon M S et al
71
7
13
95
Iran 76 Azinmehr L et al 11
Turkey 25 (Izmir)
34 (Izmir)
8 (SE)
9 (Ddiyarbakir)
Koumlse S et al
Akpinar Z et al
Turhanoglu M et al
Gulsun S et al
26
40
41
58
EASL Monothematic Conference Delta Hepatitis 2010
Prevalence of Hepatitis Delta in the Asia-Pacific RegionData presented at the EASL Delta Conference 2010
Le Gal et al Emerg Infect Dis 2006
Prevalence of Hepatitis Delta in Africa
Genotypes 1 5-8
Anti-HDV Prevalence among HBsAg-positive patients in Europe (EK Manesis EASL Special Conference 2010)
Gaeta Rizzetto et al Hepatology 2000
0
5
10
15
20
25
30
0-29 30-49 gt50
1987
1992
1997
Age of Patients
a
nti
-HD
V-p
osi
tive
H
BsA
g+
Decline of anti-HDV Prevalence in Eastern Europe in the 1990rsquos
Older DataHDV Epidemiology in the USA
Highly variable lt1 to 30 among chronic HBV carriers
NHANES IV (CDC 2003-2004)
128 HBsAg+ individuals was anti-HDV+ (36)
Nath et al Am J Epidemiol 1985
Blood Donors 14 Southeast to 12 Pacific region
Weisfuse et al Hepatology 1989
Homosexual Men 2
Rizzetto et al JID 1982 Troisi et al Blood 1993
Haemophiliacs 19 Female Prostitutes 21
Hershow et al Ann Intern Med 1989
Hepatitis B Carriers in Illinois 30
Njei Hepatology 2016
Njei Hepatology 2016
HDV infections in the US population
26 reported past IVdruguse
bull Baltimore (n=194258) prevalence declined from 15 to 11 in IVD between 1988-1989 and 2005-20062
o However among those with CHB prevalence increased to 50
bull US Veterans (n=2175 HBsAg + and tested for HDV) 34positive3
bull NHANES 1999-2012 weighted data 002 prevalence
bull 8 HDV in HBV patients San Francisco (2012)
bull Need for improved surveillance in the US
bull Recent indications that HDV prevalence is increasing
bull HDV prevalence in US was not assessed widely
1
Gish et al 2013 J Gastroenterol Hepatol2Kucirka et al 2010 J Infect Dis
3Kushner et al 2015 J Hepatol4 Njei et al 2016 Hepatol
HDV Epidemiology in the USANorthern California
Journal of Gastroenterology and Hepatology Gish et al 2013
1296 HBsAg positive patients (incomplete data) rarr 82 (63) anti-HDV positive
bull 71 malebull 54 non-hispanic Caucasiansbull 28 asian-pac immigrantsbull 34 anti-HCV positive (with 67 cirrhosis)
499 HBsAg positive patients (complete data) rarr 42 (84) anti-HDV positive
HDV in the US VA
bull 35 of HBsAg+ who where tested were anti-HDV positive
bull Predictors of being HDV tested includedbull male gender (45 vs 13 p lt0001)bull Asian ethnicity (85 vs le5 any other p lt0001)bull HBcIgM+ status (29 vs 90 of HBcIgM- plt0001)bull HBeAg+ (213 vs 130 HBeAg- plt0001)bull HCVAb+ (53 vs 43 HCVAb- plt0001)bull HIV+ (94 vs 40 HIV- plt0001)bull ALT (peak plusmn 180d 383 vs 95ul plt0001)bull HBV DNA gt 2000 IUml (218 vs 147 plt 0001)[
Kushner AASLD 2015 (see notes)
HDV in the US VA (part 2)
bull 74 HDV+ individuals
ndash 43 (58) were HCVAb+
ndash 7 (95) HIV-coinfected
ndash There was no difference in age ethnicity or comorbidity in HDV+ and HDV-subjects
ndash 69 of HDV+ were HBeAg- 74 HBeAb+ and 2326 (88) had HBV DNA titers lt2000 IUml
Kushner AASLD 2015
HDV Epidemiology in the US
Kurcirka et al JID 2010
Participation in the 1st International Quality Control for HDV RNA Quantitation (2013)
Le Gal et al 2016 HepatolHayden HDIN AASLD 2016
Newly Diagnosed HDV Patients in the US(Unique Patients)
4946 4274
4841 5043 5259 5916
6386
7442
9079
-
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
2008 2009 2010 2011 2012 2013 2014 2015 2016Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Chronic HBV Pts and Pts with HDV
00
20
40
60
80
100
120
140
-
10000
20000
30000
40000
50000
60000
2008 2009 2010 2011 2012 2013 2014 2015 2016
o
f C
hro
nic
HB
V P
ts w
ith
HD
V
New
ly D
xC
hro
nic
HB
V P
ts
Newly Dx Chronic HBV Patients (Unique) of Chronic HBV with HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV Tests Ordered and Chronic HBV Patients Tested for HDV
00
10
20
30
40
50
-
1000
2000
3000
4000
5000
200820092010201120122013201420152016 C
hro
nic
HB
V T
este
d f
or
HD
V
HD
V T
ests
Ord
ere
d
HDV Test Claims (CPT 86692) Chronic HBV Tested for HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Top 20 US Geographies for HDV Patients
650
569
429424
351
272
196146145129122122109104090089084084084081
000
100
200
300
400
500
600
700
Bro
okl
yn N
Y
Ch
icag
o I
L
Bro
nx
NY
Co
ron
a N
Y
Hu
nti
ngt
on
hellip
New
Yo
rk N
Y
Jam
aica
NY
Scar
sdal
e N
Y
Ber
wyn
IL
Ph
ilad
elp
hihellip
Pas
saic
NJ
Ho
ust
on
TX
Mia
mi
FL
San
hellip
Hia
leah
FL
Par
kvill
e M
D
Gai
nes
ville
hellip
Ovi
edo
FL
Yon
kers
NY
Hem
pst
ead
hellip
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Comparison of HDV Patient Footprint 2008 vs 2016 and Top 20 Geographies for Each Year
2008 2016
1 Brooklyn NY 6 Bronx NY 11 La Puente CA 16 Chicago IL
2 New York NY 7 Philadelphia PA 12 St Petersburg FL 17 Franklin MA
3 Yonkers NY 8 Jamaica NY 13 Staten Island NY 18 Las Vegas NV
4 Corona NY 9 San Francisco CA 14 Pittsburg CA 19 Newburgh NY
5 Scarsdale NY 10 Passaic NJ 15 Detroit MI 20 Huntington ST NY
1 Chicago IL 6 New York NY 11 Huntington ST NY 16 Cicero IL
2 Berwyn IL 7 Bronx NY 12 Philadelphia PA 17 Parkville MD
3 Brooklyn NY 8 Jamaica NY 13 Houston TX 18 Miami FL
4 Corona NY 9 Lombard NY 14 Passaic NJ 19 Hialeah FL
5 Waukegan IL 10 Aurora IL 15 Staten Island NY 20 Las Vegas NV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDV Virology
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HDV Transmission requires HBsAg
HDV Epidemiology
Mario Rizzetto Cold Spring Harb Perspect Med 20155a021576
HDV = delta-virus delta-agent Always found in association
with HBV-infection Worldwide infection asymp15-20
million The most common routes of
transmissionndash intravenous transmission (IDU)ndash percutaneous transmission (tattoo
piercing)ndash sexually transmissionndash intrafamilial transmission
Endemic regionsndash Mongoliandash Mediterranean countries (most
often in children and young people)ndash Far East (infectiousness varies from
90 among HBsAg-carriers living in the Pacific Islands up to 5 HBsAg-carriers in Japan)
ndash Amazonia
HDV TESTING RECOMMENDATIONSamong HBsAg+ Individuals
bullAASLD Guidelines ldquoLaboratory tests should include assessment of liver disease markers of HBV replication and tests for coinfection with HCV HDV or HIV in those at riskrdquo which includes all individuals from HDV endemic areas and those with history of IDUrdquo
bullEASL Guidelines ldquoOther causes of chronic liver disease should be systematically looked for including co-infections with HDV HCV andor HIV (A1)rdquo
bullAPASL Guidelines ldquoOther causes of chronic liver disease should be systematically looked for including coinfections with HDVrdquo
Different HDV Genotypes in Different Regions
Wedemeyer amp Manns Nat Rev Gastroenterol 2010
Hughes et al The Lancet 2011 Abbas et al World J Gastroenterol 2012
Prevalence of Hepatitis Delta by Genotype in the Asia-Pacific Region
Country Prevalence Author Poster
No
India 152
109
Raja WA et al
Asim M
82
8
Korea 04 (OLT) Jung Y J et al 47
Pakistan 352
453
400
453
Mumtaz K et al
Zaki M et al
Bhatti TA et al
Memon M S et al
71
7
13
95
Iran 76 Azinmehr L et al 11
Turkey 25 (Izmir)
34 (Izmir)
8 (SE)
9 (Ddiyarbakir)
Koumlse S et al
Akpinar Z et al
Turhanoglu M et al
Gulsun S et al
26
40
41
58
EASL Monothematic Conference Delta Hepatitis 2010
Prevalence of Hepatitis Delta in the Asia-Pacific RegionData presented at the EASL Delta Conference 2010
Le Gal et al Emerg Infect Dis 2006
Prevalence of Hepatitis Delta in Africa
Genotypes 1 5-8
Anti-HDV Prevalence among HBsAg-positive patients in Europe (EK Manesis EASL Special Conference 2010)
Gaeta Rizzetto et al Hepatology 2000
0
5
10
15
20
25
30
0-29 30-49 gt50
1987
1992
1997
Age of Patients
a
nti
-HD
V-p
osi
tive
H
BsA
g+
Decline of anti-HDV Prevalence in Eastern Europe in the 1990rsquos
Older DataHDV Epidemiology in the USA
Highly variable lt1 to 30 among chronic HBV carriers
NHANES IV (CDC 2003-2004)
128 HBsAg+ individuals was anti-HDV+ (36)
Nath et al Am J Epidemiol 1985
Blood Donors 14 Southeast to 12 Pacific region
Weisfuse et al Hepatology 1989
Homosexual Men 2
Rizzetto et al JID 1982 Troisi et al Blood 1993
Haemophiliacs 19 Female Prostitutes 21
Hershow et al Ann Intern Med 1989
Hepatitis B Carriers in Illinois 30
Njei Hepatology 2016
Njei Hepatology 2016
HDV infections in the US population
26 reported past IVdruguse
bull Baltimore (n=194258) prevalence declined from 15 to 11 in IVD between 1988-1989 and 2005-20062
o However among those with CHB prevalence increased to 50
bull US Veterans (n=2175 HBsAg + and tested for HDV) 34positive3
bull NHANES 1999-2012 weighted data 002 prevalence
bull 8 HDV in HBV patients San Francisco (2012)
bull Need for improved surveillance in the US
bull Recent indications that HDV prevalence is increasing
bull HDV prevalence in US was not assessed widely
1
Gish et al 2013 J Gastroenterol Hepatol2Kucirka et al 2010 J Infect Dis
3Kushner et al 2015 J Hepatol4 Njei et al 2016 Hepatol
HDV Epidemiology in the USANorthern California
Journal of Gastroenterology and Hepatology Gish et al 2013
1296 HBsAg positive patients (incomplete data) rarr 82 (63) anti-HDV positive
bull 71 malebull 54 non-hispanic Caucasiansbull 28 asian-pac immigrantsbull 34 anti-HCV positive (with 67 cirrhosis)
499 HBsAg positive patients (complete data) rarr 42 (84) anti-HDV positive
HDV in the US VA
bull 35 of HBsAg+ who where tested were anti-HDV positive
bull Predictors of being HDV tested includedbull male gender (45 vs 13 p lt0001)bull Asian ethnicity (85 vs le5 any other p lt0001)bull HBcIgM+ status (29 vs 90 of HBcIgM- plt0001)bull HBeAg+ (213 vs 130 HBeAg- plt0001)bull HCVAb+ (53 vs 43 HCVAb- plt0001)bull HIV+ (94 vs 40 HIV- plt0001)bull ALT (peak plusmn 180d 383 vs 95ul plt0001)bull HBV DNA gt 2000 IUml (218 vs 147 plt 0001)[
Kushner AASLD 2015 (see notes)
HDV in the US VA (part 2)
bull 74 HDV+ individuals
ndash 43 (58) were HCVAb+
ndash 7 (95) HIV-coinfected
ndash There was no difference in age ethnicity or comorbidity in HDV+ and HDV-subjects
ndash 69 of HDV+ were HBeAg- 74 HBeAb+ and 2326 (88) had HBV DNA titers lt2000 IUml
Kushner AASLD 2015
HDV Epidemiology in the US
Kurcirka et al JID 2010
Participation in the 1st International Quality Control for HDV RNA Quantitation (2013)
Le Gal et al 2016 HepatolHayden HDIN AASLD 2016
Newly Diagnosed HDV Patients in the US(Unique Patients)
4946 4274
4841 5043 5259 5916
6386
7442
9079
-
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
2008 2009 2010 2011 2012 2013 2014 2015 2016Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Chronic HBV Pts and Pts with HDV
00
20
40
60
80
100
120
140
-
10000
20000
30000
40000
50000
60000
2008 2009 2010 2011 2012 2013 2014 2015 2016
o
f C
hro
nic
HB
V P
ts w
ith
HD
V
New
ly D
xC
hro
nic
HB
V P
ts
Newly Dx Chronic HBV Patients (Unique) of Chronic HBV with HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV Tests Ordered and Chronic HBV Patients Tested for HDV
00
10
20
30
40
50
-
1000
2000
3000
4000
5000
200820092010201120122013201420152016 C
hro
nic
HB
V T
este
d f
or
HD
V
HD
V T
ests
Ord
ere
d
HDV Test Claims (CPT 86692) Chronic HBV Tested for HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Top 20 US Geographies for HDV Patients
650
569
429424
351
272
196146145129122122109104090089084084084081
000
100
200
300
400
500
600
700
Bro
okl
yn N
Y
Ch
icag
o I
L
Bro
nx
NY
Co
ron
a N
Y
Hu
nti
ngt
on
hellip
New
Yo
rk N
Y
Jam
aica
NY
Scar
sdal
e N
Y
Ber
wyn
IL
Ph
ilad
elp
hihellip
Pas
saic
NJ
Ho
ust
on
TX
Mia
mi
FL
San
hellip
Hia
leah
FL
Par
kvill
e M
D
Gai
nes
ville
hellip
Ovi
edo
FL
Yon
kers
NY
Hem
pst
ead
hellip
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Comparison of HDV Patient Footprint 2008 vs 2016 and Top 20 Geographies for Each Year
2008 2016
1 Brooklyn NY 6 Bronx NY 11 La Puente CA 16 Chicago IL
2 New York NY 7 Philadelphia PA 12 St Petersburg FL 17 Franklin MA
3 Yonkers NY 8 Jamaica NY 13 Staten Island NY 18 Las Vegas NV
4 Corona NY 9 San Francisco CA 14 Pittsburg CA 19 Newburgh NY
5 Scarsdale NY 10 Passaic NJ 15 Detroit MI 20 Huntington ST NY
1 Chicago IL 6 New York NY 11 Huntington ST NY 16 Cicero IL
2 Berwyn IL 7 Bronx NY 12 Philadelphia PA 17 Parkville MD
3 Brooklyn NY 8 Jamaica NY 13 Houston TX 18 Miami FL
4 Corona NY 9 Lombard NY 14 Passaic NJ 19 Hialeah FL
5 Waukegan IL 10 Aurora IL 15 Staten Island NY 20 Las Vegas NV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDV Epidemiology
Mario Rizzetto Cold Spring Harb Perspect Med 20155a021576
HDV = delta-virus delta-agent Always found in association
with HBV-infection Worldwide infection asymp15-20
million The most common routes of
transmissionndash intravenous transmission (IDU)ndash percutaneous transmission (tattoo
piercing)ndash sexually transmissionndash intrafamilial transmission
Endemic regionsndash Mongoliandash Mediterranean countries (most
often in children and young people)ndash Far East (infectiousness varies from
90 among HBsAg-carriers living in the Pacific Islands up to 5 HBsAg-carriers in Japan)
ndash Amazonia
HDV TESTING RECOMMENDATIONSamong HBsAg+ Individuals
bullAASLD Guidelines ldquoLaboratory tests should include assessment of liver disease markers of HBV replication and tests for coinfection with HCV HDV or HIV in those at riskrdquo which includes all individuals from HDV endemic areas and those with history of IDUrdquo
bullEASL Guidelines ldquoOther causes of chronic liver disease should be systematically looked for including co-infections with HDV HCV andor HIV (A1)rdquo
bullAPASL Guidelines ldquoOther causes of chronic liver disease should be systematically looked for including coinfections with HDVrdquo
Different HDV Genotypes in Different Regions
Wedemeyer amp Manns Nat Rev Gastroenterol 2010
Hughes et al The Lancet 2011 Abbas et al World J Gastroenterol 2012
Prevalence of Hepatitis Delta by Genotype in the Asia-Pacific Region
Country Prevalence Author Poster
No
India 152
109
Raja WA et al
Asim M
82
8
Korea 04 (OLT) Jung Y J et al 47
Pakistan 352
453
400
453
Mumtaz K et al
Zaki M et al
Bhatti TA et al
Memon M S et al
71
7
13
95
Iran 76 Azinmehr L et al 11
Turkey 25 (Izmir)
34 (Izmir)
8 (SE)
9 (Ddiyarbakir)
Koumlse S et al
Akpinar Z et al
Turhanoglu M et al
Gulsun S et al
26
40
41
58
EASL Monothematic Conference Delta Hepatitis 2010
Prevalence of Hepatitis Delta in the Asia-Pacific RegionData presented at the EASL Delta Conference 2010
Le Gal et al Emerg Infect Dis 2006
Prevalence of Hepatitis Delta in Africa
Genotypes 1 5-8
Anti-HDV Prevalence among HBsAg-positive patients in Europe (EK Manesis EASL Special Conference 2010)
Gaeta Rizzetto et al Hepatology 2000
0
5
10
15
20
25
30
0-29 30-49 gt50
1987
1992
1997
Age of Patients
a
nti
-HD
V-p
osi
tive
H
BsA
g+
Decline of anti-HDV Prevalence in Eastern Europe in the 1990rsquos
Older DataHDV Epidemiology in the USA
Highly variable lt1 to 30 among chronic HBV carriers
NHANES IV (CDC 2003-2004)
128 HBsAg+ individuals was anti-HDV+ (36)
Nath et al Am J Epidemiol 1985
Blood Donors 14 Southeast to 12 Pacific region
Weisfuse et al Hepatology 1989
Homosexual Men 2
Rizzetto et al JID 1982 Troisi et al Blood 1993
Haemophiliacs 19 Female Prostitutes 21
Hershow et al Ann Intern Med 1989
Hepatitis B Carriers in Illinois 30
Njei Hepatology 2016
Njei Hepatology 2016
HDV infections in the US population
26 reported past IVdruguse
bull Baltimore (n=194258) prevalence declined from 15 to 11 in IVD between 1988-1989 and 2005-20062
o However among those with CHB prevalence increased to 50
bull US Veterans (n=2175 HBsAg + and tested for HDV) 34positive3
bull NHANES 1999-2012 weighted data 002 prevalence
bull 8 HDV in HBV patients San Francisco (2012)
bull Need for improved surveillance in the US
bull Recent indications that HDV prevalence is increasing
bull HDV prevalence in US was not assessed widely
1
Gish et al 2013 J Gastroenterol Hepatol2Kucirka et al 2010 J Infect Dis
3Kushner et al 2015 J Hepatol4 Njei et al 2016 Hepatol
HDV Epidemiology in the USANorthern California
Journal of Gastroenterology and Hepatology Gish et al 2013
1296 HBsAg positive patients (incomplete data) rarr 82 (63) anti-HDV positive
bull 71 malebull 54 non-hispanic Caucasiansbull 28 asian-pac immigrantsbull 34 anti-HCV positive (with 67 cirrhosis)
499 HBsAg positive patients (complete data) rarr 42 (84) anti-HDV positive
HDV in the US VA
bull 35 of HBsAg+ who where tested were anti-HDV positive
bull Predictors of being HDV tested includedbull male gender (45 vs 13 p lt0001)bull Asian ethnicity (85 vs le5 any other p lt0001)bull HBcIgM+ status (29 vs 90 of HBcIgM- plt0001)bull HBeAg+ (213 vs 130 HBeAg- plt0001)bull HCVAb+ (53 vs 43 HCVAb- plt0001)bull HIV+ (94 vs 40 HIV- plt0001)bull ALT (peak plusmn 180d 383 vs 95ul plt0001)bull HBV DNA gt 2000 IUml (218 vs 147 plt 0001)[
Kushner AASLD 2015 (see notes)
HDV in the US VA (part 2)
bull 74 HDV+ individuals
ndash 43 (58) were HCVAb+
ndash 7 (95) HIV-coinfected
ndash There was no difference in age ethnicity or comorbidity in HDV+ and HDV-subjects
ndash 69 of HDV+ were HBeAg- 74 HBeAb+ and 2326 (88) had HBV DNA titers lt2000 IUml
Kushner AASLD 2015
HDV Epidemiology in the US
Kurcirka et al JID 2010
Participation in the 1st International Quality Control for HDV RNA Quantitation (2013)
Le Gal et al 2016 HepatolHayden HDIN AASLD 2016
Newly Diagnosed HDV Patients in the US(Unique Patients)
4946 4274
4841 5043 5259 5916
6386
7442
9079
-
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
2008 2009 2010 2011 2012 2013 2014 2015 2016Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Chronic HBV Pts and Pts with HDV
00
20
40
60
80
100
120
140
-
10000
20000
30000
40000
50000
60000
2008 2009 2010 2011 2012 2013 2014 2015 2016
o
f C
hro
nic
HB
V P
ts w
ith
HD
V
New
ly D
xC
hro
nic
HB
V P
ts
Newly Dx Chronic HBV Patients (Unique) of Chronic HBV with HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV Tests Ordered and Chronic HBV Patients Tested for HDV
00
10
20
30
40
50
-
1000
2000
3000
4000
5000
200820092010201120122013201420152016 C
hro
nic
HB
V T
este
d f
or
HD
V
HD
V T
ests
Ord
ere
d
HDV Test Claims (CPT 86692) Chronic HBV Tested for HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Top 20 US Geographies for HDV Patients
650
569
429424
351
272
196146145129122122109104090089084084084081
000
100
200
300
400
500
600
700
Bro
okl
yn N
Y
Ch
icag
o I
L
Bro
nx
NY
Co
ron
a N
Y
Hu
nti
ngt
on
hellip
New
Yo
rk N
Y
Jam
aica
NY
Scar
sdal
e N
Y
Ber
wyn
IL
Ph
ilad
elp
hihellip
Pas
saic
NJ
Ho
ust
on
TX
Mia
mi
FL
San
hellip
Hia
leah
FL
Par
kvill
e M
D
Gai
nes
ville
hellip
Ovi
edo
FL
Yon
kers
NY
Hem
pst
ead
hellip
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Comparison of HDV Patient Footprint 2008 vs 2016 and Top 20 Geographies for Each Year
2008 2016
1 Brooklyn NY 6 Bronx NY 11 La Puente CA 16 Chicago IL
2 New York NY 7 Philadelphia PA 12 St Petersburg FL 17 Franklin MA
3 Yonkers NY 8 Jamaica NY 13 Staten Island NY 18 Las Vegas NV
4 Corona NY 9 San Francisco CA 14 Pittsburg CA 19 Newburgh NY
5 Scarsdale NY 10 Passaic NJ 15 Detroit MI 20 Huntington ST NY
1 Chicago IL 6 New York NY 11 Huntington ST NY 16 Cicero IL
2 Berwyn IL 7 Bronx NY 12 Philadelphia PA 17 Parkville MD
3 Brooklyn NY 8 Jamaica NY 13 Houston TX 18 Miami FL
4 Corona NY 9 Lombard NY 14 Passaic NJ 19 Hialeah FL
5 Waukegan IL 10 Aurora IL 15 Staten Island NY 20 Las Vegas NV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDV TESTING RECOMMENDATIONSamong HBsAg+ Individuals
bullAASLD Guidelines ldquoLaboratory tests should include assessment of liver disease markers of HBV replication and tests for coinfection with HCV HDV or HIV in those at riskrdquo which includes all individuals from HDV endemic areas and those with history of IDUrdquo
bullEASL Guidelines ldquoOther causes of chronic liver disease should be systematically looked for including co-infections with HDV HCV andor HIV (A1)rdquo
bullAPASL Guidelines ldquoOther causes of chronic liver disease should be systematically looked for including coinfections with HDVrdquo
Different HDV Genotypes in Different Regions
Wedemeyer amp Manns Nat Rev Gastroenterol 2010
Hughes et al The Lancet 2011 Abbas et al World J Gastroenterol 2012
Prevalence of Hepatitis Delta by Genotype in the Asia-Pacific Region
Country Prevalence Author Poster
No
India 152
109
Raja WA et al
Asim M
82
8
Korea 04 (OLT) Jung Y J et al 47
Pakistan 352
453
400
453
Mumtaz K et al
Zaki M et al
Bhatti TA et al
Memon M S et al
71
7
13
95
Iran 76 Azinmehr L et al 11
Turkey 25 (Izmir)
34 (Izmir)
8 (SE)
9 (Ddiyarbakir)
Koumlse S et al
Akpinar Z et al
Turhanoglu M et al
Gulsun S et al
26
40
41
58
EASL Monothematic Conference Delta Hepatitis 2010
Prevalence of Hepatitis Delta in the Asia-Pacific RegionData presented at the EASL Delta Conference 2010
Le Gal et al Emerg Infect Dis 2006
Prevalence of Hepatitis Delta in Africa
Genotypes 1 5-8
Anti-HDV Prevalence among HBsAg-positive patients in Europe (EK Manesis EASL Special Conference 2010)
Gaeta Rizzetto et al Hepatology 2000
0
5
10
15
20
25
30
0-29 30-49 gt50
1987
1992
1997
Age of Patients
a
nti
-HD
V-p
osi
tive
H
BsA
g+
Decline of anti-HDV Prevalence in Eastern Europe in the 1990rsquos
Older DataHDV Epidemiology in the USA
Highly variable lt1 to 30 among chronic HBV carriers
NHANES IV (CDC 2003-2004)
128 HBsAg+ individuals was anti-HDV+ (36)
Nath et al Am J Epidemiol 1985
Blood Donors 14 Southeast to 12 Pacific region
Weisfuse et al Hepatology 1989
Homosexual Men 2
Rizzetto et al JID 1982 Troisi et al Blood 1993
Haemophiliacs 19 Female Prostitutes 21
Hershow et al Ann Intern Med 1989
Hepatitis B Carriers in Illinois 30
Njei Hepatology 2016
Njei Hepatology 2016
HDV infections in the US population
26 reported past IVdruguse
bull Baltimore (n=194258) prevalence declined from 15 to 11 in IVD between 1988-1989 and 2005-20062
o However among those with CHB prevalence increased to 50
bull US Veterans (n=2175 HBsAg + and tested for HDV) 34positive3
bull NHANES 1999-2012 weighted data 002 prevalence
bull 8 HDV in HBV patients San Francisco (2012)
bull Need for improved surveillance in the US
bull Recent indications that HDV prevalence is increasing
bull HDV prevalence in US was not assessed widely
1
Gish et al 2013 J Gastroenterol Hepatol2Kucirka et al 2010 J Infect Dis
3Kushner et al 2015 J Hepatol4 Njei et al 2016 Hepatol
HDV Epidemiology in the USANorthern California
Journal of Gastroenterology and Hepatology Gish et al 2013
1296 HBsAg positive patients (incomplete data) rarr 82 (63) anti-HDV positive
bull 71 malebull 54 non-hispanic Caucasiansbull 28 asian-pac immigrantsbull 34 anti-HCV positive (with 67 cirrhosis)
499 HBsAg positive patients (complete data) rarr 42 (84) anti-HDV positive
HDV in the US VA
bull 35 of HBsAg+ who where tested were anti-HDV positive
bull Predictors of being HDV tested includedbull male gender (45 vs 13 p lt0001)bull Asian ethnicity (85 vs le5 any other p lt0001)bull HBcIgM+ status (29 vs 90 of HBcIgM- plt0001)bull HBeAg+ (213 vs 130 HBeAg- plt0001)bull HCVAb+ (53 vs 43 HCVAb- plt0001)bull HIV+ (94 vs 40 HIV- plt0001)bull ALT (peak plusmn 180d 383 vs 95ul plt0001)bull HBV DNA gt 2000 IUml (218 vs 147 plt 0001)[
Kushner AASLD 2015 (see notes)
HDV in the US VA (part 2)
bull 74 HDV+ individuals
ndash 43 (58) were HCVAb+
ndash 7 (95) HIV-coinfected
ndash There was no difference in age ethnicity or comorbidity in HDV+ and HDV-subjects
ndash 69 of HDV+ were HBeAg- 74 HBeAb+ and 2326 (88) had HBV DNA titers lt2000 IUml
Kushner AASLD 2015
HDV Epidemiology in the US
Kurcirka et al JID 2010
Participation in the 1st International Quality Control for HDV RNA Quantitation (2013)
Le Gal et al 2016 HepatolHayden HDIN AASLD 2016
Newly Diagnosed HDV Patients in the US(Unique Patients)
4946 4274
4841 5043 5259 5916
6386
7442
9079
-
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
2008 2009 2010 2011 2012 2013 2014 2015 2016Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Chronic HBV Pts and Pts with HDV
00
20
40
60
80
100
120
140
-
10000
20000
30000
40000
50000
60000
2008 2009 2010 2011 2012 2013 2014 2015 2016
o
f C
hro
nic
HB
V P
ts w
ith
HD
V
New
ly D
xC
hro
nic
HB
V P
ts
Newly Dx Chronic HBV Patients (Unique) of Chronic HBV with HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV Tests Ordered and Chronic HBV Patients Tested for HDV
00
10
20
30
40
50
-
1000
2000
3000
4000
5000
200820092010201120122013201420152016 C
hro
nic
HB
V T
este
d f
or
HD
V
HD
V T
ests
Ord
ere
d
HDV Test Claims (CPT 86692) Chronic HBV Tested for HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Top 20 US Geographies for HDV Patients
650
569
429424
351
272
196146145129122122109104090089084084084081
000
100
200
300
400
500
600
700
Bro
okl
yn N
Y
Ch
icag
o I
L
Bro
nx
NY
Co
ron
a N
Y
Hu
nti
ngt
on
hellip
New
Yo
rk N
Y
Jam
aica
NY
Scar
sdal
e N
Y
Ber
wyn
IL
Ph
ilad
elp
hihellip
Pas
saic
NJ
Ho
ust
on
TX
Mia
mi
FL
San
hellip
Hia
leah
FL
Par
kvill
e M
D
Gai
nes
ville
hellip
Ovi
edo
FL
Yon
kers
NY
Hem
pst
ead
hellip
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Comparison of HDV Patient Footprint 2008 vs 2016 and Top 20 Geographies for Each Year
2008 2016
1 Brooklyn NY 6 Bronx NY 11 La Puente CA 16 Chicago IL
2 New York NY 7 Philadelphia PA 12 St Petersburg FL 17 Franklin MA
3 Yonkers NY 8 Jamaica NY 13 Staten Island NY 18 Las Vegas NV
4 Corona NY 9 San Francisco CA 14 Pittsburg CA 19 Newburgh NY
5 Scarsdale NY 10 Passaic NJ 15 Detroit MI 20 Huntington ST NY
1 Chicago IL 6 New York NY 11 Huntington ST NY 16 Cicero IL
2 Berwyn IL 7 Bronx NY 12 Philadelphia PA 17 Parkville MD
3 Brooklyn NY 8 Jamaica NY 13 Houston TX 18 Miami FL
4 Corona NY 9 Lombard NY 14 Passaic NJ 19 Hialeah FL
5 Waukegan IL 10 Aurora IL 15 Staten Island NY 20 Las Vegas NV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Different HDV Genotypes in Different Regions
Wedemeyer amp Manns Nat Rev Gastroenterol 2010
Hughes et al The Lancet 2011 Abbas et al World J Gastroenterol 2012
Prevalence of Hepatitis Delta by Genotype in the Asia-Pacific Region
Country Prevalence Author Poster
No
India 152
109
Raja WA et al
Asim M
82
8
Korea 04 (OLT) Jung Y J et al 47
Pakistan 352
453
400
453
Mumtaz K et al
Zaki M et al
Bhatti TA et al
Memon M S et al
71
7
13
95
Iran 76 Azinmehr L et al 11
Turkey 25 (Izmir)
34 (Izmir)
8 (SE)
9 (Ddiyarbakir)
Koumlse S et al
Akpinar Z et al
Turhanoglu M et al
Gulsun S et al
26
40
41
58
EASL Monothematic Conference Delta Hepatitis 2010
Prevalence of Hepatitis Delta in the Asia-Pacific RegionData presented at the EASL Delta Conference 2010
Le Gal et al Emerg Infect Dis 2006
Prevalence of Hepatitis Delta in Africa
Genotypes 1 5-8
Anti-HDV Prevalence among HBsAg-positive patients in Europe (EK Manesis EASL Special Conference 2010)
Gaeta Rizzetto et al Hepatology 2000
0
5
10
15
20
25
30
0-29 30-49 gt50
1987
1992
1997
Age of Patients
a
nti
-HD
V-p
osi
tive
H
BsA
g+
Decline of anti-HDV Prevalence in Eastern Europe in the 1990rsquos
Older DataHDV Epidemiology in the USA
Highly variable lt1 to 30 among chronic HBV carriers
NHANES IV (CDC 2003-2004)
128 HBsAg+ individuals was anti-HDV+ (36)
Nath et al Am J Epidemiol 1985
Blood Donors 14 Southeast to 12 Pacific region
Weisfuse et al Hepatology 1989
Homosexual Men 2
Rizzetto et al JID 1982 Troisi et al Blood 1993
Haemophiliacs 19 Female Prostitutes 21
Hershow et al Ann Intern Med 1989
Hepatitis B Carriers in Illinois 30
Njei Hepatology 2016
Njei Hepatology 2016
HDV infections in the US population
26 reported past IVdruguse
bull Baltimore (n=194258) prevalence declined from 15 to 11 in IVD between 1988-1989 and 2005-20062
o However among those with CHB prevalence increased to 50
bull US Veterans (n=2175 HBsAg + and tested for HDV) 34positive3
bull NHANES 1999-2012 weighted data 002 prevalence
bull 8 HDV in HBV patients San Francisco (2012)
bull Need for improved surveillance in the US
bull Recent indications that HDV prevalence is increasing
bull HDV prevalence in US was not assessed widely
1
Gish et al 2013 J Gastroenterol Hepatol2Kucirka et al 2010 J Infect Dis
3Kushner et al 2015 J Hepatol4 Njei et al 2016 Hepatol
HDV Epidemiology in the USANorthern California
Journal of Gastroenterology and Hepatology Gish et al 2013
1296 HBsAg positive patients (incomplete data) rarr 82 (63) anti-HDV positive
bull 71 malebull 54 non-hispanic Caucasiansbull 28 asian-pac immigrantsbull 34 anti-HCV positive (with 67 cirrhosis)
499 HBsAg positive patients (complete data) rarr 42 (84) anti-HDV positive
HDV in the US VA
bull 35 of HBsAg+ who where tested were anti-HDV positive
bull Predictors of being HDV tested includedbull male gender (45 vs 13 p lt0001)bull Asian ethnicity (85 vs le5 any other p lt0001)bull HBcIgM+ status (29 vs 90 of HBcIgM- plt0001)bull HBeAg+ (213 vs 130 HBeAg- plt0001)bull HCVAb+ (53 vs 43 HCVAb- plt0001)bull HIV+ (94 vs 40 HIV- plt0001)bull ALT (peak plusmn 180d 383 vs 95ul plt0001)bull HBV DNA gt 2000 IUml (218 vs 147 plt 0001)[
Kushner AASLD 2015 (see notes)
HDV in the US VA (part 2)
bull 74 HDV+ individuals
ndash 43 (58) were HCVAb+
ndash 7 (95) HIV-coinfected
ndash There was no difference in age ethnicity or comorbidity in HDV+ and HDV-subjects
ndash 69 of HDV+ were HBeAg- 74 HBeAb+ and 2326 (88) had HBV DNA titers lt2000 IUml
Kushner AASLD 2015
HDV Epidemiology in the US
Kurcirka et al JID 2010
Participation in the 1st International Quality Control for HDV RNA Quantitation (2013)
Le Gal et al 2016 HepatolHayden HDIN AASLD 2016
Newly Diagnosed HDV Patients in the US(Unique Patients)
4946 4274
4841 5043 5259 5916
6386
7442
9079
-
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
2008 2009 2010 2011 2012 2013 2014 2015 2016Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Chronic HBV Pts and Pts with HDV
00
20
40
60
80
100
120
140
-
10000
20000
30000
40000
50000
60000
2008 2009 2010 2011 2012 2013 2014 2015 2016
o
f C
hro
nic
HB
V P
ts w
ith
HD
V
New
ly D
xC
hro
nic
HB
V P
ts
Newly Dx Chronic HBV Patients (Unique) of Chronic HBV with HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV Tests Ordered and Chronic HBV Patients Tested for HDV
00
10
20
30
40
50
-
1000
2000
3000
4000
5000
200820092010201120122013201420152016 C
hro
nic
HB
V T
este
d f
or
HD
V
HD
V T
ests
Ord
ere
d
HDV Test Claims (CPT 86692) Chronic HBV Tested for HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Top 20 US Geographies for HDV Patients
650
569
429424
351
272
196146145129122122109104090089084084084081
000
100
200
300
400
500
600
700
Bro
okl
yn N
Y
Ch
icag
o I
L
Bro
nx
NY
Co
ron
a N
Y
Hu
nti
ngt
on
hellip
New
Yo
rk N
Y
Jam
aica
NY
Scar
sdal
e N
Y
Ber
wyn
IL
Ph
ilad
elp
hihellip
Pas
saic
NJ
Ho
ust
on
TX
Mia
mi
FL
San
hellip
Hia
leah
FL
Par
kvill
e M
D
Gai
nes
ville
hellip
Ovi
edo
FL
Yon
kers
NY
Hem
pst
ead
hellip
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Comparison of HDV Patient Footprint 2008 vs 2016 and Top 20 Geographies for Each Year
2008 2016
1 Brooklyn NY 6 Bronx NY 11 La Puente CA 16 Chicago IL
2 New York NY 7 Philadelphia PA 12 St Petersburg FL 17 Franklin MA
3 Yonkers NY 8 Jamaica NY 13 Staten Island NY 18 Las Vegas NV
4 Corona NY 9 San Francisco CA 14 Pittsburg CA 19 Newburgh NY
5 Scarsdale NY 10 Passaic NJ 15 Detroit MI 20 Huntington ST NY
1 Chicago IL 6 New York NY 11 Huntington ST NY 16 Cicero IL
2 Berwyn IL 7 Bronx NY 12 Philadelphia PA 17 Parkville MD
3 Brooklyn NY 8 Jamaica NY 13 Houston TX 18 Miami FL
4 Corona NY 9 Lombard NY 14 Passaic NJ 19 Hialeah FL
5 Waukegan IL 10 Aurora IL 15 Staten Island NY 20 Las Vegas NV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Hughes et al The Lancet 2011 Abbas et al World J Gastroenterol 2012
Prevalence of Hepatitis Delta by Genotype in the Asia-Pacific Region
Country Prevalence Author Poster
No
India 152
109
Raja WA et al
Asim M
82
8
Korea 04 (OLT) Jung Y J et al 47
Pakistan 352
453
400
453
Mumtaz K et al
Zaki M et al
Bhatti TA et al
Memon M S et al
71
7
13
95
Iran 76 Azinmehr L et al 11
Turkey 25 (Izmir)
34 (Izmir)
8 (SE)
9 (Ddiyarbakir)
Koumlse S et al
Akpinar Z et al
Turhanoglu M et al
Gulsun S et al
26
40
41
58
EASL Monothematic Conference Delta Hepatitis 2010
Prevalence of Hepatitis Delta in the Asia-Pacific RegionData presented at the EASL Delta Conference 2010
Le Gal et al Emerg Infect Dis 2006
Prevalence of Hepatitis Delta in Africa
Genotypes 1 5-8
Anti-HDV Prevalence among HBsAg-positive patients in Europe (EK Manesis EASL Special Conference 2010)
Gaeta Rizzetto et al Hepatology 2000
0
5
10
15
20
25
30
0-29 30-49 gt50
1987
1992
1997
Age of Patients
a
nti
-HD
V-p
osi
tive
H
BsA
g+
Decline of anti-HDV Prevalence in Eastern Europe in the 1990rsquos
Older DataHDV Epidemiology in the USA
Highly variable lt1 to 30 among chronic HBV carriers
NHANES IV (CDC 2003-2004)
128 HBsAg+ individuals was anti-HDV+ (36)
Nath et al Am J Epidemiol 1985
Blood Donors 14 Southeast to 12 Pacific region
Weisfuse et al Hepatology 1989
Homosexual Men 2
Rizzetto et al JID 1982 Troisi et al Blood 1993
Haemophiliacs 19 Female Prostitutes 21
Hershow et al Ann Intern Med 1989
Hepatitis B Carriers in Illinois 30
Njei Hepatology 2016
Njei Hepatology 2016
HDV infections in the US population
26 reported past IVdruguse
bull Baltimore (n=194258) prevalence declined from 15 to 11 in IVD between 1988-1989 and 2005-20062
o However among those with CHB prevalence increased to 50
bull US Veterans (n=2175 HBsAg + and tested for HDV) 34positive3
bull NHANES 1999-2012 weighted data 002 prevalence
bull 8 HDV in HBV patients San Francisco (2012)
bull Need for improved surveillance in the US
bull Recent indications that HDV prevalence is increasing
bull HDV prevalence in US was not assessed widely
1
Gish et al 2013 J Gastroenterol Hepatol2Kucirka et al 2010 J Infect Dis
3Kushner et al 2015 J Hepatol4 Njei et al 2016 Hepatol
HDV Epidemiology in the USANorthern California
Journal of Gastroenterology and Hepatology Gish et al 2013
1296 HBsAg positive patients (incomplete data) rarr 82 (63) anti-HDV positive
bull 71 malebull 54 non-hispanic Caucasiansbull 28 asian-pac immigrantsbull 34 anti-HCV positive (with 67 cirrhosis)
499 HBsAg positive patients (complete data) rarr 42 (84) anti-HDV positive
HDV in the US VA
bull 35 of HBsAg+ who where tested were anti-HDV positive
bull Predictors of being HDV tested includedbull male gender (45 vs 13 p lt0001)bull Asian ethnicity (85 vs le5 any other p lt0001)bull HBcIgM+ status (29 vs 90 of HBcIgM- plt0001)bull HBeAg+ (213 vs 130 HBeAg- plt0001)bull HCVAb+ (53 vs 43 HCVAb- plt0001)bull HIV+ (94 vs 40 HIV- plt0001)bull ALT (peak plusmn 180d 383 vs 95ul plt0001)bull HBV DNA gt 2000 IUml (218 vs 147 plt 0001)[
Kushner AASLD 2015 (see notes)
HDV in the US VA (part 2)
bull 74 HDV+ individuals
ndash 43 (58) were HCVAb+
ndash 7 (95) HIV-coinfected
ndash There was no difference in age ethnicity or comorbidity in HDV+ and HDV-subjects
ndash 69 of HDV+ were HBeAg- 74 HBeAb+ and 2326 (88) had HBV DNA titers lt2000 IUml
Kushner AASLD 2015
HDV Epidemiology in the US
Kurcirka et al JID 2010
Participation in the 1st International Quality Control for HDV RNA Quantitation (2013)
Le Gal et al 2016 HepatolHayden HDIN AASLD 2016
Newly Diagnosed HDV Patients in the US(Unique Patients)
4946 4274
4841 5043 5259 5916
6386
7442
9079
-
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
2008 2009 2010 2011 2012 2013 2014 2015 2016Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Chronic HBV Pts and Pts with HDV
00
20
40
60
80
100
120
140
-
10000
20000
30000
40000
50000
60000
2008 2009 2010 2011 2012 2013 2014 2015 2016
o
f C
hro
nic
HB
V P
ts w
ith
HD
V
New
ly D
xC
hro
nic
HB
V P
ts
Newly Dx Chronic HBV Patients (Unique) of Chronic HBV with HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV Tests Ordered and Chronic HBV Patients Tested for HDV
00
10
20
30
40
50
-
1000
2000
3000
4000
5000
200820092010201120122013201420152016 C
hro
nic
HB
V T
este
d f
or
HD
V
HD
V T
ests
Ord
ere
d
HDV Test Claims (CPT 86692) Chronic HBV Tested for HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Top 20 US Geographies for HDV Patients
650
569
429424
351
272
196146145129122122109104090089084084084081
000
100
200
300
400
500
600
700
Bro
okl
yn N
Y
Ch
icag
o I
L
Bro
nx
NY
Co
ron
a N
Y
Hu
nti
ngt
on
hellip
New
Yo
rk N
Y
Jam
aica
NY
Scar
sdal
e N
Y
Ber
wyn
IL
Ph
ilad
elp
hihellip
Pas
saic
NJ
Ho
ust
on
TX
Mia
mi
FL
San
hellip
Hia
leah
FL
Par
kvill
e M
D
Gai
nes
ville
hellip
Ovi
edo
FL
Yon
kers
NY
Hem
pst
ead
hellip
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Comparison of HDV Patient Footprint 2008 vs 2016 and Top 20 Geographies for Each Year
2008 2016
1 Brooklyn NY 6 Bronx NY 11 La Puente CA 16 Chicago IL
2 New York NY 7 Philadelphia PA 12 St Petersburg FL 17 Franklin MA
3 Yonkers NY 8 Jamaica NY 13 Staten Island NY 18 Las Vegas NV
4 Corona NY 9 San Francisco CA 14 Pittsburg CA 19 Newburgh NY
5 Scarsdale NY 10 Passaic NJ 15 Detroit MI 20 Huntington ST NY
1 Chicago IL 6 New York NY 11 Huntington ST NY 16 Cicero IL
2 Berwyn IL 7 Bronx NY 12 Philadelphia PA 17 Parkville MD
3 Brooklyn NY 8 Jamaica NY 13 Houston TX 18 Miami FL
4 Corona NY 9 Lombard NY 14 Passaic NJ 19 Hialeah FL
5 Waukegan IL 10 Aurora IL 15 Staten Island NY 20 Las Vegas NV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Country Prevalence Author Poster
No
India 152
109
Raja WA et al
Asim M
82
8
Korea 04 (OLT) Jung Y J et al 47
Pakistan 352
453
400
453
Mumtaz K et al
Zaki M et al
Bhatti TA et al
Memon M S et al
71
7
13
95
Iran 76 Azinmehr L et al 11
Turkey 25 (Izmir)
34 (Izmir)
8 (SE)
9 (Ddiyarbakir)
Koumlse S et al
Akpinar Z et al
Turhanoglu M et al
Gulsun S et al
26
40
41
58
EASL Monothematic Conference Delta Hepatitis 2010
Prevalence of Hepatitis Delta in the Asia-Pacific RegionData presented at the EASL Delta Conference 2010
Le Gal et al Emerg Infect Dis 2006
Prevalence of Hepatitis Delta in Africa
Genotypes 1 5-8
Anti-HDV Prevalence among HBsAg-positive patients in Europe (EK Manesis EASL Special Conference 2010)
Gaeta Rizzetto et al Hepatology 2000
0
5
10
15
20
25
30
0-29 30-49 gt50
1987
1992
1997
Age of Patients
a
nti
-HD
V-p
osi
tive
H
BsA
g+
Decline of anti-HDV Prevalence in Eastern Europe in the 1990rsquos
Older DataHDV Epidemiology in the USA
Highly variable lt1 to 30 among chronic HBV carriers
NHANES IV (CDC 2003-2004)
128 HBsAg+ individuals was anti-HDV+ (36)
Nath et al Am J Epidemiol 1985
Blood Donors 14 Southeast to 12 Pacific region
Weisfuse et al Hepatology 1989
Homosexual Men 2
Rizzetto et al JID 1982 Troisi et al Blood 1993
Haemophiliacs 19 Female Prostitutes 21
Hershow et al Ann Intern Med 1989
Hepatitis B Carriers in Illinois 30
Njei Hepatology 2016
Njei Hepatology 2016
HDV infections in the US population
26 reported past IVdruguse
bull Baltimore (n=194258) prevalence declined from 15 to 11 in IVD between 1988-1989 and 2005-20062
o However among those with CHB prevalence increased to 50
bull US Veterans (n=2175 HBsAg + and tested for HDV) 34positive3
bull NHANES 1999-2012 weighted data 002 prevalence
bull 8 HDV in HBV patients San Francisco (2012)
bull Need for improved surveillance in the US
bull Recent indications that HDV prevalence is increasing
bull HDV prevalence in US was not assessed widely
1
Gish et al 2013 J Gastroenterol Hepatol2Kucirka et al 2010 J Infect Dis
3Kushner et al 2015 J Hepatol4 Njei et al 2016 Hepatol
HDV Epidemiology in the USANorthern California
Journal of Gastroenterology and Hepatology Gish et al 2013
1296 HBsAg positive patients (incomplete data) rarr 82 (63) anti-HDV positive
bull 71 malebull 54 non-hispanic Caucasiansbull 28 asian-pac immigrantsbull 34 anti-HCV positive (with 67 cirrhosis)
499 HBsAg positive patients (complete data) rarr 42 (84) anti-HDV positive
HDV in the US VA
bull 35 of HBsAg+ who where tested were anti-HDV positive
bull Predictors of being HDV tested includedbull male gender (45 vs 13 p lt0001)bull Asian ethnicity (85 vs le5 any other p lt0001)bull HBcIgM+ status (29 vs 90 of HBcIgM- plt0001)bull HBeAg+ (213 vs 130 HBeAg- plt0001)bull HCVAb+ (53 vs 43 HCVAb- plt0001)bull HIV+ (94 vs 40 HIV- plt0001)bull ALT (peak plusmn 180d 383 vs 95ul plt0001)bull HBV DNA gt 2000 IUml (218 vs 147 plt 0001)[
Kushner AASLD 2015 (see notes)
HDV in the US VA (part 2)
bull 74 HDV+ individuals
ndash 43 (58) were HCVAb+
ndash 7 (95) HIV-coinfected
ndash There was no difference in age ethnicity or comorbidity in HDV+ and HDV-subjects
ndash 69 of HDV+ were HBeAg- 74 HBeAb+ and 2326 (88) had HBV DNA titers lt2000 IUml
Kushner AASLD 2015
HDV Epidemiology in the US
Kurcirka et al JID 2010
Participation in the 1st International Quality Control for HDV RNA Quantitation (2013)
Le Gal et al 2016 HepatolHayden HDIN AASLD 2016
Newly Diagnosed HDV Patients in the US(Unique Patients)
4946 4274
4841 5043 5259 5916
6386
7442
9079
-
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
2008 2009 2010 2011 2012 2013 2014 2015 2016Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Chronic HBV Pts and Pts with HDV
00
20
40
60
80
100
120
140
-
10000
20000
30000
40000
50000
60000
2008 2009 2010 2011 2012 2013 2014 2015 2016
o
f C
hro
nic
HB
V P
ts w
ith
HD
V
New
ly D
xC
hro
nic
HB
V P
ts
Newly Dx Chronic HBV Patients (Unique) of Chronic HBV with HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV Tests Ordered and Chronic HBV Patients Tested for HDV
00
10
20
30
40
50
-
1000
2000
3000
4000
5000
200820092010201120122013201420152016 C
hro
nic
HB
V T
este
d f
or
HD
V
HD
V T
ests
Ord
ere
d
HDV Test Claims (CPT 86692) Chronic HBV Tested for HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Top 20 US Geographies for HDV Patients
650
569
429424
351
272
196146145129122122109104090089084084084081
000
100
200
300
400
500
600
700
Bro
okl
yn N
Y
Ch
icag
o I
L
Bro
nx
NY
Co
ron
a N
Y
Hu
nti
ngt
on
hellip
New
Yo
rk N
Y
Jam
aica
NY
Scar
sdal
e N
Y
Ber
wyn
IL
Ph
ilad
elp
hihellip
Pas
saic
NJ
Ho
ust
on
TX
Mia
mi
FL
San
hellip
Hia
leah
FL
Par
kvill
e M
D
Gai
nes
ville
hellip
Ovi
edo
FL
Yon
kers
NY
Hem
pst
ead
hellip
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Comparison of HDV Patient Footprint 2008 vs 2016 and Top 20 Geographies for Each Year
2008 2016
1 Brooklyn NY 6 Bronx NY 11 La Puente CA 16 Chicago IL
2 New York NY 7 Philadelphia PA 12 St Petersburg FL 17 Franklin MA
3 Yonkers NY 8 Jamaica NY 13 Staten Island NY 18 Las Vegas NV
4 Corona NY 9 San Francisco CA 14 Pittsburg CA 19 Newburgh NY
5 Scarsdale NY 10 Passaic NJ 15 Detroit MI 20 Huntington ST NY
1 Chicago IL 6 New York NY 11 Huntington ST NY 16 Cicero IL
2 Berwyn IL 7 Bronx NY 12 Philadelphia PA 17 Parkville MD
3 Brooklyn NY 8 Jamaica NY 13 Houston TX 18 Miami FL
4 Corona NY 9 Lombard NY 14 Passaic NJ 19 Hialeah FL
5 Waukegan IL 10 Aurora IL 15 Staten Island NY 20 Las Vegas NV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Le Gal et al Emerg Infect Dis 2006
Prevalence of Hepatitis Delta in Africa
Genotypes 1 5-8
Anti-HDV Prevalence among HBsAg-positive patients in Europe (EK Manesis EASL Special Conference 2010)
Gaeta Rizzetto et al Hepatology 2000
0
5
10
15
20
25
30
0-29 30-49 gt50
1987
1992
1997
Age of Patients
a
nti
-HD
V-p
osi
tive
H
BsA
g+
Decline of anti-HDV Prevalence in Eastern Europe in the 1990rsquos
Older DataHDV Epidemiology in the USA
Highly variable lt1 to 30 among chronic HBV carriers
NHANES IV (CDC 2003-2004)
128 HBsAg+ individuals was anti-HDV+ (36)
Nath et al Am J Epidemiol 1985
Blood Donors 14 Southeast to 12 Pacific region
Weisfuse et al Hepatology 1989
Homosexual Men 2
Rizzetto et al JID 1982 Troisi et al Blood 1993
Haemophiliacs 19 Female Prostitutes 21
Hershow et al Ann Intern Med 1989
Hepatitis B Carriers in Illinois 30
Njei Hepatology 2016
Njei Hepatology 2016
HDV infections in the US population
26 reported past IVdruguse
bull Baltimore (n=194258) prevalence declined from 15 to 11 in IVD between 1988-1989 and 2005-20062
o However among those with CHB prevalence increased to 50
bull US Veterans (n=2175 HBsAg + and tested for HDV) 34positive3
bull NHANES 1999-2012 weighted data 002 prevalence
bull 8 HDV in HBV patients San Francisco (2012)
bull Need for improved surveillance in the US
bull Recent indications that HDV prevalence is increasing
bull HDV prevalence in US was not assessed widely
1
Gish et al 2013 J Gastroenterol Hepatol2Kucirka et al 2010 J Infect Dis
3Kushner et al 2015 J Hepatol4 Njei et al 2016 Hepatol
HDV Epidemiology in the USANorthern California
Journal of Gastroenterology and Hepatology Gish et al 2013
1296 HBsAg positive patients (incomplete data) rarr 82 (63) anti-HDV positive
bull 71 malebull 54 non-hispanic Caucasiansbull 28 asian-pac immigrantsbull 34 anti-HCV positive (with 67 cirrhosis)
499 HBsAg positive patients (complete data) rarr 42 (84) anti-HDV positive
HDV in the US VA
bull 35 of HBsAg+ who where tested were anti-HDV positive
bull Predictors of being HDV tested includedbull male gender (45 vs 13 p lt0001)bull Asian ethnicity (85 vs le5 any other p lt0001)bull HBcIgM+ status (29 vs 90 of HBcIgM- plt0001)bull HBeAg+ (213 vs 130 HBeAg- plt0001)bull HCVAb+ (53 vs 43 HCVAb- plt0001)bull HIV+ (94 vs 40 HIV- plt0001)bull ALT (peak plusmn 180d 383 vs 95ul plt0001)bull HBV DNA gt 2000 IUml (218 vs 147 plt 0001)[
Kushner AASLD 2015 (see notes)
HDV in the US VA (part 2)
bull 74 HDV+ individuals
ndash 43 (58) were HCVAb+
ndash 7 (95) HIV-coinfected
ndash There was no difference in age ethnicity or comorbidity in HDV+ and HDV-subjects
ndash 69 of HDV+ were HBeAg- 74 HBeAb+ and 2326 (88) had HBV DNA titers lt2000 IUml
Kushner AASLD 2015
HDV Epidemiology in the US
Kurcirka et al JID 2010
Participation in the 1st International Quality Control for HDV RNA Quantitation (2013)
Le Gal et al 2016 HepatolHayden HDIN AASLD 2016
Newly Diagnosed HDV Patients in the US(Unique Patients)
4946 4274
4841 5043 5259 5916
6386
7442
9079
-
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
2008 2009 2010 2011 2012 2013 2014 2015 2016Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Chronic HBV Pts and Pts with HDV
00
20
40
60
80
100
120
140
-
10000
20000
30000
40000
50000
60000
2008 2009 2010 2011 2012 2013 2014 2015 2016
o
f C
hro
nic
HB
V P
ts w
ith
HD
V
New
ly D
xC
hro
nic
HB
V P
ts
Newly Dx Chronic HBV Patients (Unique) of Chronic HBV with HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV Tests Ordered and Chronic HBV Patients Tested for HDV
00
10
20
30
40
50
-
1000
2000
3000
4000
5000
200820092010201120122013201420152016 C
hro
nic
HB
V T
este
d f
or
HD
V
HD
V T
ests
Ord
ere
d
HDV Test Claims (CPT 86692) Chronic HBV Tested for HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Top 20 US Geographies for HDV Patients
650
569
429424
351
272
196146145129122122109104090089084084084081
000
100
200
300
400
500
600
700
Bro
okl
yn N
Y
Ch
icag
o I
L
Bro
nx
NY
Co
ron
a N
Y
Hu
nti
ngt
on
hellip
New
Yo
rk N
Y
Jam
aica
NY
Scar
sdal
e N
Y
Ber
wyn
IL
Ph
ilad
elp
hihellip
Pas
saic
NJ
Ho
ust
on
TX
Mia
mi
FL
San
hellip
Hia
leah
FL
Par
kvill
e M
D
Gai
nes
ville
hellip
Ovi
edo
FL
Yon
kers
NY
Hem
pst
ead
hellip
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Comparison of HDV Patient Footprint 2008 vs 2016 and Top 20 Geographies for Each Year
2008 2016
1 Brooklyn NY 6 Bronx NY 11 La Puente CA 16 Chicago IL
2 New York NY 7 Philadelphia PA 12 St Petersburg FL 17 Franklin MA
3 Yonkers NY 8 Jamaica NY 13 Staten Island NY 18 Las Vegas NV
4 Corona NY 9 San Francisco CA 14 Pittsburg CA 19 Newburgh NY
5 Scarsdale NY 10 Passaic NJ 15 Detroit MI 20 Huntington ST NY
1 Chicago IL 6 New York NY 11 Huntington ST NY 16 Cicero IL
2 Berwyn IL 7 Bronx NY 12 Philadelphia PA 17 Parkville MD
3 Brooklyn NY 8 Jamaica NY 13 Houston TX 18 Miami FL
4 Corona NY 9 Lombard NY 14 Passaic NJ 19 Hialeah FL
5 Waukegan IL 10 Aurora IL 15 Staten Island NY 20 Las Vegas NV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Anti-HDV Prevalence among HBsAg-positive patients in Europe (EK Manesis EASL Special Conference 2010)
Gaeta Rizzetto et al Hepatology 2000
0
5
10
15
20
25
30
0-29 30-49 gt50
1987
1992
1997
Age of Patients
a
nti
-HD
V-p
osi
tive
H
BsA
g+
Decline of anti-HDV Prevalence in Eastern Europe in the 1990rsquos
Older DataHDV Epidemiology in the USA
Highly variable lt1 to 30 among chronic HBV carriers
NHANES IV (CDC 2003-2004)
128 HBsAg+ individuals was anti-HDV+ (36)
Nath et al Am J Epidemiol 1985
Blood Donors 14 Southeast to 12 Pacific region
Weisfuse et al Hepatology 1989
Homosexual Men 2
Rizzetto et al JID 1982 Troisi et al Blood 1993
Haemophiliacs 19 Female Prostitutes 21
Hershow et al Ann Intern Med 1989
Hepatitis B Carriers in Illinois 30
Njei Hepatology 2016
Njei Hepatology 2016
HDV infections in the US population
26 reported past IVdruguse
bull Baltimore (n=194258) prevalence declined from 15 to 11 in IVD between 1988-1989 and 2005-20062
o However among those with CHB prevalence increased to 50
bull US Veterans (n=2175 HBsAg + and tested for HDV) 34positive3
bull NHANES 1999-2012 weighted data 002 prevalence
bull 8 HDV in HBV patients San Francisco (2012)
bull Need for improved surveillance in the US
bull Recent indications that HDV prevalence is increasing
bull HDV prevalence in US was not assessed widely
1
Gish et al 2013 J Gastroenterol Hepatol2Kucirka et al 2010 J Infect Dis
3Kushner et al 2015 J Hepatol4 Njei et al 2016 Hepatol
HDV Epidemiology in the USANorthern California
Journal of Gastroenterology and Hepatology Gish et al 2013
1296 HBsAg positive patients (incomplete data) rarr 82 (63) anti-HDV positive
bull 71 malebull 54 non-hispanic Caucasiansbull 28 asian-pac immigrantsbull 34 anti-HCV positive (with 67 cirrhosis)
499 HBsAg positive patients (complete data) rarr 42 (84) anti-HDV positive
HDV in the US VA
bull 35 of HBsAg+ who where tested were anti-HDV positive
bull Predictors of being HDV tested includedbull male gender (45 vs 13 p lt0001)bull Asian ethnicity (85 vs le5 any other p lt0001)bull HBcIgM+ status (29 vs 90 of HBcIgM- plt0001)bull HBeAg+ (213 vs 130 HBeAg- plt0001)bull HCVAb+ (53 vs 43 HCVAb- plt0001)bull HIV+ (94 vs 40 HIV- plt0001)bull ALT (peak plusmn 180d 383 vs 95ul plt0001)bull HBV DNA gt 2000 IUml (218 vs 147 plt 0001)[
Kushner AASLD 2015 (see notes)
HDV in the US VA (part 2)
bull 74 HDV+ individuals
ndash 43 (58) were HCVAb+
ndash 7 (95) HIV-coinfected
ndash There was no difference in age ethnicity or comorbidity in HDV+ and HDV-subjects
ndash 69 of HDV+ were HBeAg- 74 HBeAb+ and 2326 (88) had HBV DNA titers lt2000 IUml
Kushner AASLD 2015
HDV Epidemiology in the US
Kurcirka et al JID 2010
Participation in the 1st International Quality Control for HDV RNA Quantitation (2013)
Le Gal et al 2016 HepatolHayden HDIN AASLD 2016
Newly Diagnosed HDV Patients in the US(Unique Patients)
4946 4274
4841 5043 5259 5916
6386
7442
9079
-
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
2008 2009 2010 2011 2012 2013 2014 2015 2016Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Chronic HBV Pts and Pts with HDV
00
20
40
60
80
100
120
140
-
10000
20000
30000
40000
50000
60000
2008 2009 2010 2011 2012 2013 2014 2015 2016
o
f C
hro
nic
HB
V P
ts w
ith
HD
V
New
ly D
xC
hro
nic
HB
V P
ts
Newly Dx Chronic HBV Patients (Unique) of Chronic HBV with HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV Tests Ordered and Chronic HBV Patients Tested for HDV
00
10
20
30
40
50
-
1000
2000
3000
4000
5000
200820092010201120122013201420152016 C
hro
nic
HB
V T
este
d f
or
HD
V
HD
V T
ests
Ord
ere
d
HDV Test Claims (CPT 86692) Chronic HBV Tested for HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Top 20 US Geographies for HDV Patients
650
569
429424
351
272
196146145129122122109104090089084084084081
000
100
200
300
400
500
600
700
Bro
okl
yn N
Y
Ch
icag
o I
L
Bro
nx
NY
Co
ron
a N
Y
Hu
nti
ngt
on
hellip
New
Yo
rk N
Y
Jam
aica
NY
Scar
sdal
e N
Y
Ber
wyn
IL
Ph
ilad
elp
hihellip
Pas
saic
NJ
Ho
ust
on
TX
Mia
mi
FL
San
hellip
Hia
leah
FL
Par
kvill
e M
D
Gai
nes
ville
hellip
Ovi
edo
FL
Yon
kers
NY
Hem
pst
ead
hellip
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Comparison of HDV Patient Footprint 2008 vs 2016 and Top 20 Geographies for Each Year
2008 2016
1 Brooklyn NY 6 Bronx NY 11 La Puente CA 16 Chicago IL
2 New York NY 7 Philadelphia PA 12 St Petersburg FL 17 Franklin MA
3 Yonkers NY 8 Jamaica NY 13 Staten Island NY 18 Las Vegas NV
4 Corona NY 9 San Francisco CA 14 Pittsburg CA 19 Newburgh NY
5 Scarsdale NY 10 Passaic NJ 15 Detroit MI 20 Huntington ST NY
1 Chicago IL 6 New York NY 11 Huntington ST NY 16 Cicero IL
2 Berwyn IL 7 Bronx NY 12 Philadelphia PA 17 Parkville MD
3 Brooklyn NY 8 Jamaica NY 13 Houston TX 18 Miami FL
4 Corona NY 9 Lombard NY 14 Passaic NJ 19 Hialeah FL
5 Waukegan IL 10 Aurora IL 15 Staten Island NY 20 Las Vegas NV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Gaeta Rizzetto et al Hepatology 2000
0
5
10
15
20
25
30
0-29 30-49 gt50
1987
1992
1997
Age of Patients
a
nti
-HD
V-p
osi
tive
H
BsA
g+
Decline of anti-HDV Prevalence in Eastern Europe in the 1990rsquos
Older DataHDV Epidemiology in the USA
Highly variable lt1 to 30 among chronic HBV carriers
NHANES IV (CDC 2003-2004)
128 HBsAg+ individuals was anti-HDV+ (36)
Nath et al Am J Epidemiol 1985
Blood Donors 14 Southeast to 12 Pacific region
Weisfuse et al Hepatology 1989
Homosexual Men 2
Rizzetto et al JID 1982 Troisi et al Blood 1993
Haemophiliacs 19 Female Prostitutes 21
Hershow et al Ann Intern Med 1989
Hepatitis B Carriers in Illinois 30
Njei Hepatology 2016
Njei Hepatology 2016
HDV infections in the US population
26 reported past IVdruguse
bull Baltimore (n=194258) prevalence declined from 15 to 11 in IVD between 1988-1989 and 2005-20062
o However among those with CHB prevalence increased to 50
bull US Veterans (n=2175 HBsAg + and tested for HDV) 34positive3
bull NHANES 1999-2012 weighted data 002 prevalence
bull 8 HDV in HBV patients San Francisco (2012)
bull Need for improved surveillance in the US
bull Recent indications that HDV prevalence is increasing
bull HDV prevalence in US was not assessed widely
1
Gish et al 2013 J Gastroenterol Hepatol2Kucirka et al 2010 J Infect Dis
3Kushner et al 2015 J Hepatol4 Njei et al 2016 Hepatol
HDV Epidemiology in the USANorthern California
Journal of Gastroenterology and Hepatology Gish et al 2013
1296 HBsAg positive patients (incomplete data) rarr 82 (63) anti-HDV positive
bull 71 malebull 54 non-hispanic Caucasiansbull 28 asian-pac immigrantsbull 34 anti-HCV positive (with 67 cirrhosis)
499 HBsAg positive patients (complete data) rarr 42 (84) anti-HDV positive
HDV in the US VA
bull 35 of HBsAg+ who where tested were anti-HDV positive
bull Predictors of being HDV tested includedbull male gender (45 vs 13 p lt0001)bull Asian ethnicity (85 vs le5 any other p lt0001)bull HBcIgM+ status (29 vs 90 of HBcIgM- plt0001)bull HBeAg+ (213 vs 130 HBeAg- plt0001)bull HCVAb+ (53 vs 43 HCVAb- plt0001)bull HIV+ (94 vs 40 HIV- plt0001)bull ALT (peak plusmn 180d 383 vs 95ul plt0001)bull HBV DNA gt 2000 IUml (218 vs 147 plt 0001)[
Kushner AASLD 2015 (see notes)
HDV in the US VA (part 2)
bull 74 HDV+ individuals
ndash 43 (58) were HCVAb+
ndash 7 (95) HIV-coinfected
ndash There was no difference in age ethnicity or comorbidity in HDV+ and HDV-subjects
ndash 69 of HDV+ were HBeAg- 74 HBeAb+ and 2326 (88) had HBV DNA titers lt2000 IUml
Kushner AASLD 2015
HDV Epidemiology in the US
Kurcirka et al JID 2010
Participation in the 1st International Quality Control for HDV RNA Quantitation (2013)
Le Gal et al 2016 HepatolHayden HDIN AASLD 2016
Newly Diagnosed HDV Patients in the US(Unique Patients)
4946 4274
4841 5043 5259 5916
6386
7442
9079
-
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
2008 2009 2010 2011 2012 2013 2014 2015 2016Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Chronic HBV Pts and Pts with HDV
00
20
40
60
80
100
120
140
-
10000
20000
30000
40000
50000
60000
2008 2009 2010 2011 2012 2013 2014 2015 2016
o
f C
hro
nic
HB
V P
ts w
ith
HD
V
New
ly D
xC
hro
nic
HB
V P
ts
Newly Dx Chronic HBV Patients (Unique) of Chronic HBV with HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV Tests Ordered and Chronic HBV Patients Tested for HDV
00
10
20
30
40
50
-
1000
2000
3000
4000
5000
200820092010201120122013201420152016 C
hro
nic
HB
V T
este
d f
or
HD
V
HD
V T
ests
Ord
ere
d
HDV Test Claims (CPT 86692) Chronic HBV Tested for HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Top 20 US Geographies for HDV Patients
650
569
429424
351
272
196146145129122122109104090089084084084081
000
100
200
300
400
500
600
700
Bro
okl
yn N
Y
Ch
icag
o I
L
Bro
nx
NY
Co
ron
a N
Y
Hu
nti
ngt
on
hellip
New
Yo
rk N
Y
Jam
aica
NY
Scar
sdal
e N
Y
Ber
wyn
IL
Ph
ilad
elp
hihellip
Pas
saic
NJ
Ho
ust
on
TX
Mia
mi
FL
San
hellip
Hia
leah
FL
Par
kvill
e M
D
Gai
nes
ville
hellip
Ovi
edo
FL
Yon
kers
NY
Hem
pst
ead
hellip
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Comparison of HDV Patient Footprint 2008 vs 2016 and Top 20 Geographies for Each Year
2008 2016
1 Brooklyn NY 6 Bronx NY 11 La Puente CA 16 Chicago IL
2 New York NY 7 Philadelphia PA 12 St Petersburg FL 17 Franklin MA
3 Yonkers NY 8 Jamaica NY 13 Staten Island NY 18 Las Vegas NV
4 Corona NY 9 San Francisco CA 14 Pittsburg CA 19 Newburgh NY
5 Scarsdale NY 10 Passaic NJ 15 Detroit MI 20 Huntington ST NY
1 Chicago IL 6 New York NY 11 Huntington ST NY 16 Cicero IL
2 Berwyn IL 7 Bronx NY 12 Philadelphia PA 17 Parkville MD
3 Brooklyn NY 8 Jamaica NY 13 Houston TX 18 Miami FL
4 Corona NY 9 Lombard NY 14 Passaic NJ 19 Hialeah FL
5 Waukegan IL 10 Aurora IL 15 Staten Island NY 20 Las Vegas NV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Older DataHDV Epidemiology in the USA
Highly variable lt1 to 30 among chronic HBV carriers
NHANES IV (CDC 2003-2004)
128 HBsAg+ individuals was anti-HDV+ (36)
Nath et al Am J Epidemiol 1985
Blood Donors 14 Southeast to 12 Pacific region
Weisfuse et al Hepatology 1989
Homosexual Men 2
Rizzetto et al JID 1982 Troisi et al Blood 1993
Haemophiliacs 19 Female Prostitutes 21
Hershow et al Ann Intern Med 1989
Hepatitis B Carriers in Illinois 30
Njei Hepatology 2016
Njei Hepatology 2016
HDV infections in the US population
26 reported past IVdruguse
bull Baltimore (n=194258) prevalence declined from 15 to 11 in IVD between 1988-1989 and 2005-20062
o However among those with CHB prevalence increased to 50
bull US Veterans (n=2175 HBsAg + and tested for HDV) 34positive3
bull NHANES 1999-2012 weighted data 002 prevalence
bull 8 HDV in HBV patients San Francisco (2012)
bull Need for improved surveillance in the US
bull Recent indications that HDV prevalence is increasing
bull HDV prevalence in US was not assessed widely
1
Gish et al 2013 J Gastroenterol Hepatol2Kucirka et al 2010 J Infect Dis
3Kushner et al 2015 J Hepatol4 Njei et al 2016 Hepatol
HDV Epidemiology in the USANorthern California
Journal of Gastroenterology and Hepatology Gish et al 2013
1296 HBsAg positive patients (incomplete data) rarr 82 (63) anti-HDV positive
bull 71 malebull 54 non-hispanic Caucasiansbull 28 asian-pac immigrantsbull 34 anti-HCV positive (with 67 cirrhosis)
499 HBsAg positive patients (complete data) rarr 42 (84) anti-HDV positive
HDV in the US VA
bull 35 of HBsAg+ who where tested were anti-HDV positive
bull Predictors of being HDV tested includedbull male gender (45 vs 13 p lt0001)bull Asian ethnicity (85 vs le5 any other p lt0001)bull HBcIgM+ status (29 vs 90 of HBcIgM- plt0001)bull HBeAg+ (213 vs 130 HBeAg- plt0001)bull HCVAb+ (53 vs 43 HCVAb- plt0001)bull HIV+ (94 vs 40 HIV- plt0001)bull ALT (peak plusmn 180d 383 vs 95ul plt0001)bull HBV DNA gt 2000 IUml (218 vs 147 plt 0001)[
Kushner AASLD 2015 (see notes)
HDV in the US VA (part 2)
bull 74 HDV+ individuals
ndash 43 (58) were HCVAb+
ndash 7 (95) HIV-coinfected
ndash There was no difference in age ethnicity or comorbidity in HDV+ and HDV-subjects
ndash 69 of HDV+ were HBeAg- 74 HBeAb+ and 2326 (88) had HBV DNA titers lt2000 IUml
Kushner AASLD 2015
HDV Epidemiology in the US
Kurcirka et al JID 2010
Participation in the 1st International Quality Control for HDV RNA Quantitation (2013)
Le Gal et al 2016 HepatolHayden HDIN AASLD 2016
Newly Diagnosed HDV Patients in the US(Unique Patients)
4946 4274
4841 5043 5259 5916
6386
7442
9079
-
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
2008 2009 2010 2011 2012 2013 2014 2015 2016Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Chronic HBV Pts and Pts with HDV
00
20
40
60
80
100
120
140
-
10000
20000
30000
40000
50000
60000
2008 2009 2010 2011 2012 2013 2014 2015 2016
o
f C
hro
nic
HB
V P
ts w
ith
HD
V
New
ly D
xC
hro
nic
HB
V P
ts
Newly Dx Chronic HBV Patients (Unique) of Chronic HBV with HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV Tests Ordered and Chronic HBV Patients Tested for HDV
00
10
20
30
40
50
-
1000
2000
3000
4000
5000
200820092010201120122013201420152016 C
hro
nic
HB
V T
este
d f
or
HD
V
HD
V T
ests
Ord
ere
d
HDV Test Claims (CPT 86692) Chronic HBV Tested for HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Top 20 US Geographies for HDV Patients
650
569
429424
351
272
196146145129122122109104090089084084084081
000
100
200
300
400
500
600
700
Bro
okl
yn N
Y
Ch
icag
o I
L
Bro
nx
NY
Co
ron
a N
Y
Hu
nti
ngt
on
hellip
New
Yo
rk N
Y
Jam
aica
NY
Scar
sdal
e N
Y
Ber
wyn
IL
Ph
ilad
elp
hihellip
Pas
saic
NJ
Ho
ust
on
TX
Mia
mi
FL
San
hellip
Hia
leah
FL
Par
kvill
e M
D
Gai
nes
ville
hellip
Ovi
edo
FL
Yon
kers
NY
Hem
pst
ead
hellip
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Comparison of HDV Patient Footprint 2008 vs 2016 and Top 20 Geographies for Each Year
2008 2016
1 Brooklyn NY 6 Bronx NY 11 La Puente CA 16 Chicago IL
2 New York NY 7 Philadelphia PA 12 St Petersburg FL 17 Franklin MA
3 Yonkers NY 8 Jamaica NY 13 Staten Island NY 18 Las Vegas NV
4 Corona NY 9 San Francisco CA 14 Pittsburg CA 19 Newburgh NY
5 Scarsdale NY 10 Passaic NJ 15 Detroit MI 20 Huntington ST NY
1 Chicago IL 6 New York NY 11 Huntington ST NY 16 Cicero IL
2 Berwyn IL 7 Bronx NY 12 Philadelphia PA 17 Parkville MD
3 Brooklyn NY 8 Jamaica NY 13 Houston TX 18 Miami FL
4 Corona NY 9 Lombard NY 14 Passaic NJ 19 Hialeah FL
5 Waukegan IL 10 Aurora IL 15 Staten Island NY 20 Las Vegas NV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Njei Hepatology 2016
Njei Hepatology 2016
HDV infections in the US population
26 reported past IVdruguse
bull Baltimore (n=194258) prevalence declined from 15 to 11 in IVD between 1988-1989 and 2005-20062
o However among those with CHB prevalence increased to 50
bull US Veterans (n=2175 HBsAg + and tested for HDV) 34positive3
bull NHANES 1999-2012 weighted data 002 prevalence
bull 8 HDV in HBV patients San Francisco (2012)
bull Need for improved surveillance in the US
bull Recent indications that HDV prevalence is increasing
bull HDV prevalence in US was not assessed widely
1
Gish et al 2013 J Gastroenterol Hepatol2Kucirka et al 2010 J Infect Dis
3Kushner et al 2015 J Hepatol4 Njei et al 2016 Hepatol
HDV Epidemiology in the USANorthern California
Journal of Gastroenterology and Hepatology Gish et al 2013
1296 HBsAg positive patients (incomplete data) rarr 82 (63) anti-HDV positive
bull 71 malebull 54 non-hispanic Caucasiansbull 28 asian-pac immigrantsbull 34 anti-HCV positive (with 67 cirrhosis)
499 HBsAg positive patients (complete data) rarr 42 (84) anti-HDV positive
HDV in the US VA
bull 35 of HBsAg+ who where tested were anti-HDV positive
bull Predictors of being HDV tested includedbull male gender (45 vs 13 p lt0001)bull Asian ethnicity (85 vs le5 any other p lt0001)bull HBcIgM+ status (29 vs 90 of HBcIgM- plt0001)bull HBeAg+ (213 vs 130 HBeAg- plt0001)bull HCVAb+ (53 vs 43 HCVAb- plt0001)bull HIV+ (94 vs 40 HIV- plt0001)bull ALT (peak plusmn 180d 383 vs 95ul plt0001)bull HBV DNA gt 2000 IUml (218 vs 147 plt 0001)[
Kushner AASLD 2015 (see notes)
HDV in the US VA (part 2)
bull 74 HDV+ individuals
ndash 43 (58) were HCVAb+
ndash 7 (95) HIV-coinfected
ndash There was no difference in age ethnicity or comorbidity in HDV+ and HDV-subjects
ndash 69 of HDV+ were HBeAg- 74 HBeAb+ and 2326 (88) had HBV DNA titers lt2000 IUml
Kushner AASLD 2015
HDV Epidemiology in the US
Kurcirka et al JID 2010
Participation in the 1st International Quality Control for HDV RNA Quantitation (2013)
Le Gal et al 2016 HepatolHayden HDIN AASLD 2016
Newly Diagnosed HDV Patients in the US(Unique Patients)
4946 4274
4841 5043 5259 5916
6386
7442
9079
-
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
2008 2009 2010 2011 2012 2013 2014 2015 2016Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Chronic HBV Pts and Pts with HDV
00
20
40
60
80
100
120
140
-
10000
20000
30000
40000
50000
60000
2008 2009 2010 2011 2012 2013 2014 2015 2016
o
f C
hro
nic
HB
V P
ts w
ith
HD
V
New
ly D
xC
hro
nic
HB
V P
ts
Newly Dx Chronic HBV Patients (Unique) of Chronic HBV with HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV Tests Ordered and Chronic HBV Patients Tested for HDV
00
10
20
30
40
50
-
1000
2000
3000
4000
5000
200820092010201120122013201420152016 C
hro
nic
HB
V T
este
d f
or
HD
V
HD
V T
ests
Ord
ere
d
HDV Test Claims (CPT 86692) Chronic HBV Tested for HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Top 20 US Geographies for HDV Patients
650
569
429424
351
272
196146145129122122109104090089084084084081
000
100
200
300
400
500
600
700
Bro
okl
yn N
Y
Ch
icag
o I
L
Bro
nx
NY
Co
ron
a N
Y
Hu
nti
ngt
on
hellip
New
Yo
rk N
Y
Jam
aica
NY
Scar
sdal
e N
Y
Ber
wyn
IL
Ph
ilad
elp
hihellip
Pas
saic
NJ
Ho
ust
on
TX
Mia
mi
FL
San
hellip
Hia
leah
FL
Par
kvill
e M
D
Gai
nes
ville
hellip
Ovi
edo
FL
Yon
kers
NY
Hem
pst
ead
hellip
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Comparison of HDV Patient Footprint 2008 vs 2016 and Top 20 Geographies for Each Year
2008 2016
1 Brooklyn NY 6 Bronx NY 11 La Puente CA 16 Chicago IL
2 New York NY 7 Philadelphia PA 12 St Petersburg FL 17 Franklin MA
3 Yonkers NY 8 Jamaica NY 13 Staten Island NY 18 Las Vegas NV
4 Corona NY 9 San Francisco CA 14 Pittsburg CA 19 Newburgh NY
5 Scarsdale NY 10 Passaic NJ 15 Detroit MI 20 Huntington ST NY
1 Chicago IL 6 New York NY 11 Huntington ST NY 16 Cicero IL
2 Berwyn IL 7 Bronx NY 12 Philadelphia PA 17 Parkville MD
3 Brooklyn NY 8 Jamaica NY 13 Houston TX 18 Miami FL
4 Corona NY 9 Lombard NY 14 Passaic NJ 19 Hialeah FL
5 Waukegan IL 10 Aurora IL 15 Staten Island NY 20 Las Vegas NV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Njei Hepatology 2016
HDV infections in the US population
26 reported past IVdruguse
bull Baltimore (n=194258) prevalence declined from 15 to 11 in IVD between 1988-1989 and 2005-20062
o However among those with CHB prevalence increased to 50
bull US Veterans (n=2175 HBsAg + and tested for HDV) 34positive3
bull NHANES 1999-2012 weighted data 002 prevalence
bull 8 HDV in HBV patients San Francisco (2012)
bull Need for improved surveillance in the US
bull Recent indications that HDV prevalence is increasing
bull HDV prevalence in US was not assessed widely
1
Gish et al 2013 J Gastroenterol Hepatol2Kucirka et al 2010 J Infect Dis
3Kushner et al 2015 J Hepatol4 Njei et al 2016 Hepatol
HDV Epidemiology in the USANorthern California
Journal of Gastroenterology and Hepatology Gish et al 2013
1296 HBsAg positive patients (incomplete data) rarr 82 (63) anti-HDV positive
bull 71 malebull 54 non-hispanic Caucasiansbull 28 asian-pac immigrantsbull 34 anti-HCV positive (with 67 cirrhosis)
499 HBsAg positive patients (complete data) rarr 42 (84) anti-HDV positive
HDV in the US VA
bull 35 of HBsAg+ who where tested were anti-HDV positive
bull Predictors of being HDV tested includedbull male gender (45 vs 13 p lt0001)bull Asian ethnicity (85 vs le5 any other p lt0001)bull HBcIgM+ status (29 vs 90 of HBcIgM- plt0001)bull HBeAg+ (213 vs 130 HBeAg- plt0001)bull HCVAb+ (53 vs 43 HCVAb- plt0001)bull HIV+ (94 vs 40 HIV- plt0001)bull ALT (peak plusmn 180d 383 vs 95ul plt0001)bull HBV DNA gt 2000 IUml (218 vs 147 plt 0001)[
Kushner AASLD 2015 (see notes)
HDV in the US VA (part 2)
bull 74 HDV+ individuals
ndash 43 (58) were HCVAb+
ndash 7 (95) HIV-coinfected
ndash There was no difference in age ethnicity or comorbidity in HDV+ and HDV-subjects
ndash 69 of HDV+ were HBeAg- 74 HBeAb+ and 2326 (88) had HBV DNA titers lt2000 IUml
Kushner AASLD 2015
HDV Epidemiology in the US
Kurcirka et al JID 2010
Participation in the 1st International Quality Control for HDV RNA Quantitation (2013)
Le Gal et al 2016 HepatolHayden HDIN AASLD 2016
Newly Diagnosed HDV Patients in the US(Unique Patients)
4946 4274
4841 5043 5259 5916
6386
7442
9079
-
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
2008 2009 2010 2011 2012 2013 2014 2015 2016Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Chronic HBV Pts and Pts with HDV
00
20
40
60
80
100
120
140
-
10000
20000
30000
40000
50000
60000
2008 2009 2010 2011 2012 2013 2014 2015 2016
o
f C
hro
nic
HB
V P
ts w
ith
HD
V
New
ly D
xC
hro
nic
HB
V P
ts
Newly Dx Chronic HBV Patients (Unique) of Chronic HBV with HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV Tests Ordered and Chronic HBV Patients Tested for HDV
00
10
20
30
40
50
-
1000
2000
3000
4000
5000
200820092010201120122013201420152016 C
hro
nic
HB
V T
este
d f
or
HD
V
HD
V T
ests
Ord
ere
d
HDV Test Claims (CPT 86692) Chronic HBV Tested for HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Top 20 US Geographies for HDV Patients
650
569
429424
351
272
196146145129122122109104090089084084084081
000
100
200
300
400
500
600
700
Bro
okl
yn N
Y
Ch
icag
o I
L
Bro
nx
NY
Co
ron
a N
Y
Hu
nti
ngt
on
hellip
New
Yo
rk N
Y
Jam
aica
NY
Scar
sdal
e N
Y
Ber
wyn
IL
Ph
ilad
elp
hihellip
Pas
saic
NJ
Ho
ust
on
TX
Mia
mi
FL
San
hellip
Hia
leah
FL
Par
kvill
e M
D
Gai
nes
ville
hellip
Ovi
edo
FL
Yon
kers
NY
Hem
pst
ead
hellip
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Comparison of HDV Patient Footprint 2008 vs 2016 and Top 20 Geographies for Each Year
2008 2016
1 Brooklyn NY 6 Bronx NY 11 La Puente CA 16 Chicago IL
2 New York NY 7 Philadelphia PA 12 St Petersburg FL 17 Franklin MA
3 Yonkers NY 8 Jamaica NY 13 Staten Island NY 18 Las Vegas NV
4 Corona NY 9 San Francisco CA 14 Pittsburg CA 19 Newburgh NY
5 Scarsdale NY 10 Passaic NJ 15 Detroit MI 20 Huntington ST NY
1 Chicago IL 6 New York NY 11 Huntington ST NY 16 Cicero IL
2 Berwyn IL 7 Bronx NY 12 Philadelphia PA 17 Parkville MD
3 Brooklyn NY 8 Jamaica NY 13 Houston TX 18 Miami FL
4 Corona NY 9 Lombard NY 14 Passaic NJ 19 Hialeah FL
5 Waukegan IL 10 Aurora IL 15 Staten Island NY 20 Las Vegas NV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDV infections in the US population
26 reported past IVdruguse
bull Baltimore (n=194258) prevalence declined from 15 to 11 in IVD between 1988-1989 and 2005-20062
o However among those with CHB prevalence increased to 50
bull US Veterans (n=2175 HBsAg + and tested for HDV) 34positive3
bull NHANES 1999-2012 weighted data 002 prevalence
bull 8 HDV in HBV patients San Francisco (2012)
bull Need for improved surveillance in the US
bull Recent indications that HDV prevalence is increasing
bull HDV prevalence in US was not assessed widely
1
Gish et al 2013 J Gastroenterol Hepatol2Kucirka et al 2010 J Infect Dis
3Kushner et al 2015 J Hepatol4 Njei et al 2016 Hepatol
HDV Epidemiology in the USANorthern California
Journal of Gastroenterology and Hepatology Gish et al 2013
1296 HBsAg positive patients (incomplete data) rarr 82 (63) anti-HDV positive
bull 71 malebull 54 non-hispanic Caucasiansbull 28 asian-pac immigrantsbull 34 anti-HCV positive (with 67 cirrhosis)
499 HBsAg positive patients (complete data) rarr 42 (84) anti-HDV positive
HDV in the US VA
bull 35 of HBsAg+ who where tested were anti-HDV positive
bull Predictors of being HDV tested includedbull male gender (45 vs 13 p lt0001)bull Asian ethnicity (85 vs le5 any other p lt0001)bull HBcIgM+ status (29 vs 90 of HBcIgM- plt0001)bull HBeAg+ (213 vs 130 HBeAg- plt0001)bull HCVAb+ (53 vs 43 HCVAb- plt0001)bull HIV+ (94 vs 40 HIV- plt0001)bull ALT (peak plusmn 180d 383 vs 95ul plt0001)bull HBV DNA gt 2000 IUml (218 vs 147 plt 0001)[
Kushner AASLD 2015 (see notes)
HDV in the US VA (part 2)
bull 74 HDV+ individuals
ndash 43 (58) were HCVAb+
ndash 7 (95) HIV-coinfected
ndash There was no difference in age ethnicity or comorbidity in HDV+ and HDV-subjects
ndash 69 of HDV+ were HBeAg- 74 HBeAb+ and 2326 (88) had HBV DNA titers lt2000 IUml
Kushner AASLD 2015
HDV Epidemiology in the US
Kurcirka et al JID 2010
Participation in the 1st International Quality Control for HDV RNA Quantitation (2013)
Le Gal et al 2016 HepatolHayden HDIN AASLD 2016
Newly Diagnosed HDV Patients in the US(Unique Patients)
4946 4274
4841 5043 5259 5916
6386
7442
9079
-
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
2008 2009 2010 2011 2012 2013 2014 2015 2016Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Chronic HBV Pts and Pts with HDV
00
20
40
60
80
100
120
140
-
10000
20000
30000
40000
50000
60000
2008 2009 2010 2011 2012 2013 2014 2015 2016
o
f C
hro
nic
HB
V P
ts w
ith
HD
V
New
ly D
xC
hro
nic
HB
V P
ts
Newly Dx Chronic HBV Patients (Unique) of Chronic HBV with HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV Tests Ordered and Chronic HBV Patients Tested for HDV
00
10
20
30
40
50
-
1000
2000
3000
4000
5000
200820092010201120122013201420152016 C
hro
nic
HB
V T
este
d f
or
HD
V
HD
V T
ests
Ord
ere
d
HDV Test Claims (CPT 86692) Chronic HBV Tested for HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Top 20 US Geographies for HDV Patients
650
569
429424
351
272
196146145129122122109104090089084084084081
000
100
200
300
400
500
600
700
Bro
okl
yn N
Y
Ch
icag
o I
L
Bro
nx
NY
Co
ron
a N
Y
Hu
nti
ngt
on
hellip
New
Yo
rk N
Y
Jam
aica
NY
Scar
sdal
e N
Y
Ber
wyn
IL
Ph
ilad
elp
hihellip
Pas
saic
NJ
Ho
ust
on
TX
Mia
mi
FL
San
hellip
Hia
leah
FL
Par
kvill
e M
D
Gai
nes
ville
hellip
Ovi
edo
FL
Yon
kers
NY
Hem
pst
ead
hellip
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Comparison of HDV Patient Footprint 2008 vs 2016 and Top 20 Geographies for Each Year
2008 2016
1 Brooklyn NY 6 Bronx NY 11 La Puente CA 16 Chicago IL
2 New York NY 7 Philadelphia PA 12 St Petersburg FL 17 Franklin MA
3 Yonkers NY 8 Jamaica NY 13 Staten Island NY 18 Las Vegas NV
4 Corona NY 9 San Francisco CA 14 Pittsburg CA 19 Newburgh NY
5 Scarsdale NY 10 Passaic NJ 15 Detroit MI 20 Huntington ST NY
1 Chicago IL 6 New York NY 11 Huntington ST NY 16 Cicero IL
2 Berwyn IL 7 Bronx NY 12 Philadelphia PA 17 Parkville MD
3 Brooklyn NY 8 Jamaica NY 13 Houston TX 18 Miami FL
4 Corona NY 9 Lombard NY 14 Passaic NJ 19 Hialeah FL
5 Waukegan IL 10 Aurora IL 15 Staten Island NY 20 Las Vegas NV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDV Epidemiology in the USANorthern California
Journal of Gastroenterology and Hepatology Gish et al 2013
1296 HBsAg positive patients (incomplete data) rarr 82 (63) anti-HDV positive
bull 71 malebull 54 non-hispanic Caucasiansbull 28 asian-pac immigrantsbull 34 anti-HCV positive (with 67 cirrhosis)
499 HBsAg positive patients (complete data) rarr 42 (84) anti-HDV positive
HDV in the US VA
bull 35 of HBsAg+ who where tested were anti-HDV positive
bull Predictors of being HDV tested includedbull male gender (45 vs 13 p lt0001)bull Asian ethnicity (85 vs le5 any other p lt0001)bull HBcIgM+ status (29 vs 90 of HBcIgM- plt0001)bull HBeAg+ (213 vs 130 HBeAg- plt0001)bull HCVAb+ (53 vs 43 HCVAb- plt0001)bull HIV+ (94 vs 40 HIV- plt0001)bull ALT (peak plusmn 180d 383 vs 95ul plt0001)bull HBV DNA gt 2000 IUml (218 vs 147 plt 0001)[
Kushner AASLD 2015 (see notes)
HDV in the US VA (part 2)
bull 74 HDV+ individuals
ndash 43 (58) were HCVAb+
ndash 7 (95) HIV-coinfected
ndash There was no difference in age ethnicity or comorbidity in HDV+ and HDV-subjects
ndash 69 of HDV+ were HBeAg- 74 HBeAb+ and 2326 (88) had HBV DNA titers lt2000 IUml
Kushner AASLD 2015
HDV Epidemiology in the US
Kurcirka et al JID 2010
Participation in the 1st International Quality Control for HDV RNA Quantitation (2013)
Le Gal et al 2016 HepatolHayden HDIN AASLD 2016
Newly Diagnosed HDV Patients in the US(Unique Patients)
4946 4274
4841 5043 5259 5916
6386
7442
9079
-
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
2008 2009 2010 2011 2012 2013 2014 2015 2016Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Chronic HBV Pts and Pts with HDV
00
20
40
60
80
100
120
140
-
10000
20000
30000
40000
50000
60000
2008 2009 2010 2011 2012 2013 2014 2015 2016
o
f C
hro
nic
HB
V P
ts w
ith
HD
V
New
ly D
xC
hro
nic
HB
V P
ts
Newly Dx Chronic HBV Patients (Unique) of Chronic HBV with HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV Tests Ordered and Chronic HBV Patients Tested for HDV
00
10
20
30
40
50
-
1000
2000
3000
4000
5000
200820092010201120122013201420152016 C
hro
nic
HB
V T
este
d f
or
HD
V
HD
V T
ests
Ord
ere
d
HDV Test Claims (CPT 86692) Chronic HBV Tested for HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Top 20 US Geographies for HDV Patients
650
569
429424
351
272
196146145129122122109104090089084084084081
000
100
200
300
400
500
600
700
Bro
okl
yn N
Y
Ch
icag
o I
L
Bro
nx
NY
Co
ron
a N
Y
Hu
nti
ngt
on
hellip
New
Yo
rk N
Y
Jam
aica
NY
Scar
sdal
e N
Y
Ber
wyn
IL
Ph
ilad
elp
hihellip
Pas
saic
NJ
Ho
ust
on
TX
Mia
mi
FL
San
hellip
Hia
leah
FL
Par
kvill
e M
D
Gai
nes
ville
hellip
Ovi
edo
FL
Yon
kers
NY
Hem
pst
ead
hellip
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Comparison of HDV Patient Footprint 2008 vs 2016 and Top 20 Geographies for Each Year
2008 2016
1 Brooklyn NY 6 Bronx NY 11 La Puente CA 16 Chicago IL
2 New York NY 7 Philadelphia PA 12 St Petersburg FL 17 Franklin MA
3 Yonkers NY 8 Jamaica NY 13 Staten Island NY 18 Las Vegas NV
4 Corona NY 9 San Francisco CA 14 Pittsburg CA 19 Newburgh NY
5 Scarsdale NY 10 Passaic NJ 15 Detroit MI 20 Huntington ST NY
1 Chicago IL 6 New York NY 11 Huntington ST NY 16 Cicero IL
2 Berwyn IL 7 Bronx NY 12 Philadelphia PA 17 Parkville MD
3 Brooklyn NY 8 Jamaica NY 13 Houston TX 18 Miami FL
4 Corona NY 9 Lombard NY 14 Passaic NJ 19 Hialeah FL
5 Waukegan IL 10 Aurora IL 15 Staten Island NY 20 Las Vegas NV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDV in the US VA
bull 35 of HBsAg+ who where tested were anti-HDV positive
bull Predictors of being HDV tested includedbull male gender (45 vs 13 p lt0001)bull Asian ethnicity (85 vs le5 any other p lt0001)bull HBcIgM+ status (29 vs 90 of HBcIgM- plt0001)bull HBeAg+ (213 vs 130 HBeAg- plt0001)bull HCVAb+ (53 vs 43 HCVAb- plt0001)bull HIV+ (94 vs 40 HIV- plt0001)bull ALT (peak plusmn 180d 383 vs 95ul plt0001)bull HBV DNA gt 2000 IUml (218 vs 147 plt 0001)[
Kushner AASLD 2015 (see notes)
HDV in the US VA (part 2)
bull 74 HDV+ individuals
ndash 43 (58) were HCVAb+
ndash 7 (95) HIV-coinfected
ndash There was no difference in age ethnicity or comorbidity in HDV+ and HDV-subjects
ndash 69 of HDV+ were HBeAg- 74 HBeAb+ and 2326 (88) had HBV DNA titers lt2000 IUml
Kushner AASLD 2015
HDV Epidemiology in the US
Kurcirka et al JID 2010
Participation in the 1st International Quality Control for HDV RNA Quantitation (2013)
Le Gal et al 2016 HepatolHayden HDIN AASLD 2016
Newly Diagnosed HDV Patients in the US(Unique Patients)
4946 4274
4841 5043 5259 5916
6386
7442
9079
-
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
2008 2009 2010 2011 2012 2013 2014 2015 2016Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Chronic HBV Pts and Pts with HDV
00
20
40
60
80
100
120
140
-
10000
20000
30000
40000
50000
60000
2008 2009 2010 2011 2012 2013 2014 2015 2016
o
f C
hro
nic
HB
V P
ts w
ith
HD
V
New
ly D
xC
hro
nic
HB
V P
ts
Newly Dx Chronic HBV Patients (Unique) of Chronic HBV with HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV Tests Ordered and Chronic HBV Patients Tested for HDV
00
10
20
30
40
50
-
1000
2000
3000
4000
5000
200820092010201120122013201420152016 C
hro
nic
HB
V T
este
d f
or
HD
V
HD
V T
ests
Ord
ere
d
HDV Test Claims (CPT 86692) Chronic HBV Tested for HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Top 20 US Geographies for HDV Patients
650
569
429424
351
272
196146145129122122109104090089084084084081
000
100
200
300
400
500
600
700
Bro
okl
yn N
Y
Ch
icag
o I
L
Bro
nx
NY
Co
ron
a N
Y
Hu
nti
ngt
on
hellip
New
Yo
rk N
Y
Jam
aica
NY
Scar
sdal
e N
Y
Ber
wyn
IL
Ph
ilad
elp
hihellip
Pas
saic
NJ
Ho
ust
on
TX
Mia
mi
FL
San
hellip
Hia
leah
FL
Par
kvill
e M
D
Gai
nes
ville
hellip
Ovi
edo
FL
Yon
kers
NY
Hem
pst
ead
hellip
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Comparison of HDV Patient Footprint 2008 vs 2016 and Top 20 Geographies for Each Year
2008 2016
1 Brooklyn NY 6 Bronx NY 11 La Puente CA 16 Chicago IL
2 New York NY 7 Philadelphia PA 12 St Petersburg FL 17 Franklin MA
3 Yonkers NY 8 Jamaica NY 13 Staten Island NY 18 Las Vegas NV
4 Corona NY 9 San Francisco CA 14 Pittsburg CA 19 Newburgh NY
5 Scarsdale NY 10 Passaic NJ 15 Detroit MI 20 Huntington ST NY
1 Chicago IL 6 New York NY 11 Huntington ST NY 16 Cicero IL
2 Berwyn IL 7 Bronx NY 12 Philadelphia PA 17 Parkville MD
3 Brooklyn NY 8 Jamaica NY 13 Houston TX 18 Miami FL
4 Corona NY 9 Lombard NY 14 Passaic NJ 19 Hialeah FL
5 Waukegan IL 10 Aurora IL 15 Staten Island NY 20 Las Vegas NV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDV in the US VA (part 2)
bull 74 HDV+ individuals
ndash 43 (58) were HCVAb+
ndash 7 (95) HIV-coinfected
ndash There was no difference in age ethnicity or comorbidity in HDV+ and HDV-subjects
ndash 69 of HDV+ were HBeAg- 74 HBeAb+ and 2326 (88) had HBV DNA titers lt2000 IUml
Kushner AASLD 2015
HDV Epidemiology in the US
Kurcirka et al JID 2010
Participation in the 1st International Quality Control for HDV RNA Quantitation (2013)
Le Gal et al 2016 HepatolHayden HDIN AASLD 2016
Newly Diagnosed HDV Patients in the US(Unique Patients)
4946 4274
4841 5043 5259 5916
6386
7442
9079
-
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
2008 2009 2010 2011 2012 2013 2014 2015 2016Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Chronic HBV Pts and Pts with HDV
00
20
40
60
80
100
120
140
-
10000
20000
30000
40000
50000
60000
2008 2009 2010 2011 2012 2013 2014 2015 2016
o
f C
hro
nic
HB
V P
ts w
ith
HD
V
New
ly D
xC
hro
nic
HB
V P
ts
Newly Dx Chronic HBV Patients (Unique) of Chronic HBV with HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV Tests Ordered and Chronic HBV Patients Tested for HDV
00
10
20
30
40
50
-
1000
2000
3000
4000
5000
200820092010201120122013201420152016 C
hro
nic
HB
V T
este
d f
or
HD
V
HD
V T
ests
Ord
ere
d
HDV Test Claims (CPT 86692) Chronic HBV Tested for HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Top 20 US Geographies for HDV Patients
650
569
429424
351
272
196146145129122122109104090089084084084081
000
100
200
300
400
500
600
700
Bro
okl
yn N
Y
Ch
icag
o I
L
Bro
nx
NY
Co
ron
a N
Y
Hu
nti
ngt
on
hellip
New
Yo
rk N
Y
Jam
aica
NY
Scar
sdal
e N
Y
Ber
wyn
IL
Ph
ilad
elp
hihellip
Pas
saic
NJ
Ho
ust
on
TX
Mia
mi
FL
San
hellip
Hia
leah
FL
Par
kvill
e M
D
Gai
nes
ville
hellip
Ovi
edo
FL
Yon
kers
NY
Hem
pst
ead
hellip
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Comparison of HDV Patient Footprint 2008 vs 2016 and Top 20 Geographies for Each Year
2008 2016
1 Brooklyn NY 6 Bronx NY 11 La Puente CA 16 Chicago IL
2 New York NY 7 Philadelphia PA 12 St Petersburg FL 17 Franklin MA
3 Yonkers NY 8 Jamaica NY 13 Staten Island NY 18 Las Vegas NV
4 Corona NY 9 San Francisco CA 14 Pittsburg CA 19 Newburgh NY
5 Scarsdale NY 10 Passaic NJ 15 Detroit MI 20 Huntington ST NY
1 Chicago IL 6 New York NY 11 Huntington ST NY 16 Cicero IL
2 Berwyn IL 7 Bronx NY 12 Philadelphia PA 17 Parkville MD
3 Brooklyn NY 8 Jamaica NY 13 Houston TX 18 Miami FL
4 Corona NY 9 Lombard NY 14 Passaic NJ 19 Hialeah FL
5 Waukegan IL 10 Aurora IL 15 Staten Island NY 20 Las Vegas NV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDV Epidemiology in the US
Kurcirka et al JID 2010
Participation in the 1st International Quality Control for HDV RNA Quantitation (2013)
Le Gal et al 2016 HepatolHayden HDIN AASLD 2016
Newly Diagnosed HDV Patients in the US(Unique Patients)
4946 4274
4841 5043 5259 5916
6386
7442
9079
-
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
2008 2009 2010 2011 2012 2013 2014 2015 2016Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Chronic HBV Pts and Pts with HDV
00
20
40
60
80
100
120
140
-
10000
20000
30000
40000
50000
60000
2008 2009 2010 2011 2012 2013 2014 2015 2016
o
f C
hro
nic
HB
V P
ts w
ith
HD
V
New
ly D
xC
hro
nic
HB
V P
ts
Newly Dx Chronic HBV Patients (Unique) of Chronic HBV with HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV Tests Ordered and Chronic HBV Patients Tested for HDV
00
10
20
30
40
50
-
1000
2000
3000
4000
5000
200820092010201120122013201420152016 C
hro
nic
HB
V T
este
d f
or
HD
V
HD
V T
ests
Ord
ere
d
HDV Test Claims (CPT 86692) Chronic HBV Tested for HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Top 20 US Geographies for HDV Patients
650
569
429424
351
272
196146145129122122109104090089084084084081
000
100
200
300
400
500
600
700
Bro
okl
yn N
Y
Ch
icag
o I
L
Bro
nx
NY
Co
ron
a N
Y
Hu
nti
ngt
on
hellip
New
Yo
rk N
Y
Jam
aica
NY
Scar
sdal
e N
Y
Ber
wyn
IL
Ph
ilad
elp
hihellip
Pas
saic
NJ
Ho
ust
on
TX
Mia
mi
FL
San
hellip
Hia
leah
FL
Par
kvill
e M
D
Gai
nes
ville
hellip
Ovi
edo
FL
Yon
kers
NY
Hem
pst
ead
hellip
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Comparison of HDV Patient Footprint 2008 vs 2016 and Top 20 Geographies for Each Year
2008 2016
1 Brooklyn NY 6 Bronx NY 11 La Puente CA 16 Chicago IL
2 New York NY 7 Philadelphia PA 12 St Petersburg FL 17 Franklin MA
3 Yonkers NY 8 Jamaica NY 13 Staten Island NY 18 Las Vegas NV
4 Corona NY 9 San Francisco CA 14 Pittsburg CA 19 Newburgh NY
5 Scarsdale NY 10 Passaic NJ 15 Detroit MI 20 Huntington ST NY
1 Chicago IL 6 New York NY 11 Huntington ST NY 16 Cicero IL
2 Berwyn IL 7 Bronx NY 12 Philadelphia PA 17 Parkville MD
3 Brooklyn NY 8 Jamaica NY 13 Houston TX 18 Miami FL
4 Corona NY 9 Lombard NY 14 Passaic NJ 19 Hialeah FL
5 Waukegan IL 10 Aurora IL 15 Staten Island NY 20 Las Vegas NV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Participation in the 1st International Quality Control for HDV RNA Quantitation (2013)
Le Gal et al 2016 HepatolHayden HDIN AASLD 2016
Newly Diagnosed HDV Patients in the US(Unique Patients)
4946 4274
4841 5043 5259 5916
6386
7442
9079
-
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
2008 2009 2010 2011 2012 2013 2014 2015 2016Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Chronic HBV Pts and Pts with HDV
00
20
40
60
80
100
120
140
-
10000
20000
30000
40000
50000
60000
2008 2009 2010 2011 2012 2013 2014 2015 2016
o
f C
hro
nic
HB
V P
ts w
ith
HD
V
New
ly D
xC
hro
nic
HB
V P
ts
Newly Dx Chronic HBV Patients (Unique) of Chronic HBV with HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV Tests Ordered and Chronic HBV Patients Tested for HDV
00
10
20
30
40
50
-
1000
2000
3000
4000
5000
200820092010201120122013201420152016 C
hro
nic
HB
V T
este
d f
or
HD
V
HD
V T
ests
Ord
ere
d
HDV Test Claims (CPT 86692) Chronic HBV Tested for HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Top 20 US Geographies for HDV Patients
650
569
429424
351
272
196146145129122122109104090089084084084081
000
100
200
300
400
500
600
700
Bro
okl
yn N
Y
Ch
icag
o I
L
Bro
nx
NY
Co
ron
a N
Y
Hu
nti
ngt
on
hellip
New
Yo
rk N
Y
Jam
aica
NY
Scar
sdal
e N
Y
Ber
wyn
IL
Ph
ilad
elp
hihellip
Pas
saic
NJ
Ho
ust
on
TX
Mia
mi
FL
San
hellip
Hia
leah
FL
Par
kvill
e M
D
Gai
nes
ville
hellip
Ovi
edo
FL
Yon
kers
NY
Hem
pst
ead
hellip
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Comparison of HDV Patient Footprint 2008 vs 2016 and Top 20 Geographies for Each Year
2008 2016
1 Brooklyn NY 6 Bronx NY 11 La Puente CA 16 Chicago IL
2 New York NY 7 Philadelphia PA 12 St Petersburg FL 17 Franklin MA
3 Yonkers NY 8 Jamaica NY 13 Staten Island NY 18 Las Vegas NV
4 Corona NY 9 San Francisco CA 14 Pittsburg CA 19 Newburgh NY
5 Scarsdale NY 10 Passaic NJ 15 Detroit MI 20 Huntington ST NY
1 Chicago IL 6 New York NY 11 Huntington ST NY 16 Cicero IL
2 Berwyn IL 7 Bronx NY 12 Philadelphia PA 17 Parkville MD
3 Brooklyn NY 8 Jamaica NY 13 Houston TX 18 Miami FL
4 Corona NY 9 Lombard NY 14 Passaic NJ 19 Hialeah FL
5 Waukegan IL 10 Aurora IL 15 Staten Island NY 20 Las Vegas NV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Newly Diagnosed HDV Patients in the US(Unique Patients)
4946 4274
4841 5043 5259 5916
6386
7442
9079
-
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
2008 2009 2010 2011 2012 2013 2014 2015 2016Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Chronic HBV Pts and Pts with HDV
00
20
40
60
80
100
120
140
-
10000
20000
30000
40000
50000
60000
2008 2009 2010 2011 2012 2013 2014 2015 2016
o
f C
hro
nic
HB
V P
ts w
ith
HD
V
New
ly D
xC
hro
nic
HB
V P
ts
Newly Dx Chronic HBV Patients (Unique) of Chronic HBV with HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV Tests Ordered and Chronic HBV Patients Tested for HDV
00
10
20
30
40
50
-
1000
2000
3000
4000
5000
200820092010201120122013201420152016 C
hro
nic
HB
V T
este
d f
or
HD
V
HD
V T
ests
Ord
ere
d
HDV Test Claims (CPT 86692) Chronic HBV Tested for HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Top 20 US Geographies for HDV Patients
650
569
429424
351
272
196146145129122122109104090089084084084081
000
100
200
300
400
500
600
700
Bro
okl
yn N
Y
Ch
icag
o I
L
Bro
nx
NY
Co
ron
a N
Y
Hu
nti
ngt
on
hellip
New
Yo
rk N
Y
Jam
aica
NY
Scar
sdal
e N
Y
Ber
wyn
IL
Ph
ilad
elp
hihellip
Pas
saic
NJ
Ho
ust
on
TX
Mia
mi
FL
San
hellip
Hia
leah
FL
Par
kvill
e M
D
Gai
nes
ville
hellip
Ovi
edo
FL
Yon
kers
NY
Hem
pst
ead
hellip
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Comparison of HDV Patient Footprint 2008 vs 2016 and Top 20 Geographies for Each Year
2008 2016
1 Brooklyn NY 6 Bronx NY 11 La Puente CA 16 Chicago IL
2 New York NY 7 Philadelphia PA 12 St Petersburg FL 17 Franklin MA
3 Yonkers NY 8 Jamaica NY 13 Staten Island NY 18 Las Vegas NV
4 Corona NY 9 San Francisco CA 14 Pittsburg CA 19 Newburgh NY
5 Scarsdale NY 10 Passaic NJ 15 Detroit MI 20 Huntington ST NY
1 Chicago IL 6 New York NY 11 Huntington ST NY 16 Cicero IL
2 Berwyn IL 7 Bronx NY 12 Philadelphia PA 17 Parkville MD
3 Brooklyn NY 8 Jamaica NY 13 Houston TX 18 Miami FL
4 Corona NY 9 Lombard NY 14 Passaic NJ 19 Hialeah FL
5 Waukegan IL 10 Aurora IL 15 Staten Island NY 20 Las Vegas NV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Chronic HBV Pts and Pts with HDV
00
20
40
60
80
100
120
140
-
10000
20000
30000
40000
50000
60000
2008 2009 2010 2011 2012 2013 2014 2015 2016
o
f C
hro
nic
HB
V P
ts w
ith
HD
V
New
ly D
xC
hro
nic
HB
V P
ts
Newly Dx Chronic HBV Patients (Unique) of Chronic HBV with HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV Tests Ordered and Chronic HBV Patients Tested for HDV
00
10
20
30
40
50
-
1000
2000
3000
4000
5000
200820092010201120122013201420152016 C
hro
nic
HB
V T
este
d f
or
HD
V
HD
V T
ests
Ord
ere
d
HDV Test Claims (CPT 86692) Chronic HBV Tested for HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Top 20 US Geographies for HDV Patients
650
569
429424
351
272
196146145129122122109104090089084084084081
000
100
200
300
400
500
600
700
Bro
okl
yn N
Y
Ch
icag
o I
L
Bro
nx
NY
Co
ron
a N
Y
Hu
nti
ngt
on
hellip
New
Yo
rk N
Y
Jam
aica
NY
Scar
sdal
e N
Y
Ber
wyn
IL
Ph
ilad
elp
hihellip
Pas
saic
NJ
Ho
ust
on
TX
Mia
mi
FL
San
hellip
Hia
leah
FL
Par
kvill
e M
D
Gai
nes
ville
hellip
Ovi
edo
FL
Yon
kers
NY
Hem
pst
ead
hellip
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Comparison of HDV Patient Footprint 2008 vs 2016 and Top 20 Geographies for Each Year
2008 2016
1 Brooklyn NY 6 Bronx NY 11 La Puente CA 16 Chicago IL
2 New York NY 7 Philadelphia PA 12 St Petersburg FL 17 Franklin MA
3 Yonkers NY 8 Jamaica NY 13 Staten Island NY 18 Las Vegas NV
4 Corona NY 9 San Francisco CA 14 Pittsburg CA 19 Newburgh NY
5 Scarsdale NY 10 Passaic NJ 15 Detroit MI 20 Huntington ST NY
1 Chicago IL 6 New York NY 11 Huntington ST NY 16 Cicero IL
2 Berwyn IL 7 Bronx NY 12 Philadelphia PA 17 Parkville MD
3 Brooklyn NY 8 Jamaica NY 13 Houston TX 18 Miami FL
4 Corona NY 9 Lombard NY 14 Passaic NJ 19 Hialeah FL
5 Waukegan IL 10 Aurora IL 15 Staten Island NY 20 Las Vegas NV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDV Tests Ordered and Chronic HBV Patients Tested for HDV
00
10
20
30
40
50
-
1000
2000
3000
4000
5000
200820092010201120122013201420152016 C
hro
nic
HB
V T
este
d f
or
HD
V
HD
V T
ests
Ord
ere
d
HDV Test Claims (CPT 86692) Chronic HBV Tested for HDV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Top 20 US Geographies for HDV Patients
650
569
429424
351
272
196146145129122122109104090089084084084081
000
100
200
300
400
500
600
700
Bro
okl
yn N
Y
Ch
icag
o I
L
Bro
nx
NY
Co
ron
a N
Y
Hu
nti
ngt
on
hellip
New
Yo
rk N
Y
Jam
aica
NY
Scar
sdal
e N
Y
Ber
wyn
IL
Ph
ilad
elp
hihellip
Pas
saic
NJ
Ho
ust
on
TX
Mia
mi
FL
San
hellip
Hia
leah
FL
Par
kvill
e M
D
Gai
nes
ville
hellip
Ovi
edo
FL
Yon
kers
NY
Hem
pst
ead
hellip
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Comparison of HDV Patient Footprint 2008 vs 2016 and Top 20 Geographies for Each Year
2008 2016
1 Brooklyn NY 6 Bronx NY 11 La Puente CA 16 Chicago IL
2 New York NY 7 Philadelphia PA 12 St Petersburg FL 17 Franklin MA
3 Yonkers NY 8 Jamaica NY 13 Staten Island NY 18 Las Vegas NV
4 Corona NY 9 San Francisco CA 14 Pittsburg CA 19 Newburgh NY
5 Scarsdale NY 10 Passaic NJ 15 Detroit MI 20 Huntington ST NY
1 Chicago IL 6 New York NY 11 Huntington ST NY 16 Cicero IL
2 Berwyn IL 7 Bronx NY 12 Philadelphia PA 17 Parkville MD
3 Brooklyn NY 8 Jamaica NY 13 Houston TX 18 Miami FL
4 Corona NY 9 Lombard NY 14 Passaic NJ 19 Hialeah FL
5 Waukegan IL 10 Aurora IL 15 Staten Island NY 20 Las Vegas NV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Top 20 US Geographies for HDV Patients
650
569
429424
351
272
196146145129122122109104090089084084084081
000
100
200
300
400
500
600
700
Bro
okl
yn N
Y
Ch
icag
o I
L
Bro
nx
NY
Co
ron
a N
Y
Hu
nti
ngt
on
hellip
New
Yo
rk N
Y
Jam
aica
NY
Scar
sdal
e N
Y
Ber
wyn
IL
Ph
ilad
elp
hihellip
Pas
saic
NJ
Ho
ust
on
TX
Mia
mi
FL
San
hellip
Hia
leah
FL
Par
kvill
e M
D
Gai
nes
ville
hellip
Ovi
edo
FL
Yon
kers
NY
Hem
pst
ead
hellip
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
Comparison of HDV Patient Footprint 2008 vs 2016 and Top 20 Geographies for Each Year
2008 2016
1 Brooklyn NY 6 Bronx NY 11 La Puente CA 16 Chicago IL
2 New York NY 7 Philadelphia PA 12 St Petersburg FL 17 Franklin MA
3 Yonkers NY 8 Jamaica NY 13 Staten Island NY 18 Las Vegas NV
4 Corona NY 9 San Francisco CA 14 Pittsburg CA 19 Newburgh NY
5 Scarsdale NY 10 Passaic NJ 15 Detroit MI 20 Huntington ST NY
1 Chicago IL 6 New York NY 11 Huntington ST NY 16 Cicero IL
2 Berwyn IL 7 Bronx NY 12 Philadelphia PA 17 Parkville MD
3 Brooklyn NY 8 Jamaica NY 13 Houston TX 18 Miami FL
4 Corona NY 9 Lombard NY 14 Passaic NJ 19 Hialeah FL
5 Waukegan IL 10 Aurora IL 15 Staten Island NY 20 Las Vegas NV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Comparison of HDV Patient Footprint 2008 vs 2016 and Top 20 Geographies for Each Year
2008 2016
1 Brooklyn NY 6 Bronx NY 11 La Puente CA 16 Chicago IL
2 New York NY 7 Philadelphia PA 12 St Petersburg FL 17 Franklin MA
3 Yonkers NY 8 Jamaica NY 13 Staten Island NY 18 Las Vegas NV
4 Corona NY 9 San Francisco CA 14 Pittsburg CA 19 Newburgh NY
5 Scarsdale NY 10 Passaic NJ 15 Detroit MI 20 Huntington ST NY
1 Chicago IL 6 New York NY 11 Huntington ST NY 16 Cicero IL
2 Berwyn IL 7 Bronx NY 12 Philadelphia PA 17 Parkville MD
3 Brooklyn NY 8 Jamaica NY 13 Houston TX 18 Miami FL
4 Corona NY 9 Lombard NY 14 Passaic NJ 19 Hialeah FL
5 Waukegan IL 10 Aurora IL 15 Staten Island NY 20 Las Vegas NV
Source Martins E and Glenn J Prevalence of Hepatitis Delta Virus (HDV) Infection in the United States Results from an ICD-10 Review Poster Sa1486 DDW May 2017
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDV in a ldquolow prevalencerdquo country
bull Vietnam
Tien 2013
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDV Co- and Superinfection
Time after Exposure
Tite
r
Jaundice
Symptoms
ALTTotal anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Time after Exposure
Tite
r
anti-HBs
Symptoms
ALT Elevated
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
bull Co-infection bull Clinically indistinguishable from acute HBV
bull Usually acute and self-limited (95) HDV and HBV clearance
bull High frequency of acute liver failure in IDUs
bull Severe hepatitis in previously diagnosed HBsAg-carrier or exacerbation of a known chronic HBV
bull HDV becomes chronic almost in 90
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
Hepatitis Delta Evolution of Clinical Presentation
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
After Wedemeyer
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
198
0
199
0
200
0
201
0
ACUTE HEPATITIS DELTA
CHRONIC HEPATITIS DELTA
o
f H
Bs
Ag
+ p
ati
en
ts
young patients locally acquired
special risk groups (IVDU)
older patients
Immigrant populationsspecial risk groups
Severe Acute + Chronic Disease
Mild chronic Disease
Severe chronic Disease
After Wedemeyer
Hepatitis Delta Evolution of Clinical Presentation (Cont)
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDV Modes of Transmission
Calle Serrano Manns amp Wedemeyer Seminars in Liver Disease 2012
HBV vaccination prevents from HDV infection
Intrafamilial transmissionvertical amp sexual transmission
infection during early childhood Folk remedies scarification percutaneous exposure
Medical treatmentblood transfusion unsterile syringes etc
Special risk groupsIV drug user dialysis HIV+ hemophiliacs
HDV Transmission requires HBsAg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HBV DNA is often suppressed by HDV even in HBeAg-positive hepatitis
Heidrich et al Liver International 2012
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Schaper Buti et al J Hepatol 2010 Wedemeyer J Hepatol 2010
Fluctuating Patterns of Viral Dominancein Hepatitis D
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Surv
ival
months0 50 100 150 200
00
02
04
06
08
10HCC
Decompensation
Р=0003
Р=049
Liver Disease Progression
3645 407469 4934
152115
211170
078
135
08
04
Р=0045
Р=0005
Age
yrs
AV Nersesov EA Izatullayev LK Palgova et al Clinical peculiarities of HDV infection in Kazakhstan EASL Monothematic Conference Delta Hepatitis Istanbul Turkey Septr 24-26 2010- Abstracts- P133
Р=0001
Р=0001
CHD CHB LCD LCB
PLT
х1
09l
AP
RI
28-year prospective study in Italy 25 with liver cirrhosis developed HCC 59 - liver failure
Study in Taiwan 15 survival within 15 yrs
The main cause of death in patients with CHD is the decompensation of progressive liver disease (38) instead of hepatocellular carcinoma
G Fattovich G Giustina E Christensen et al Gut 200046420ndash426 Farci P EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Oral Bonino F Negro F Baldi M et al Prog Clin Biol Res 1987234145-152 Romeo R et al Gastroenterology 136 1629ndash1638 (2009) Su C W et al Gastroenterology 130 1625ndash1635 (2006) Calle-Serrano et al AASLD 2009 Romeo et al Gastroenterology 2009
More rapid progression
of HDV compare to HBV Patients with CHD are as
many as 105 years
younger than those with CHВ
Patients with LCD are as
many as 87 years younger than those with LCВ
More frequent
complications of LCD Portal hypertension
HE
More frequent severe
thrombocytopenia more
higher APRI
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Wranke A Heidrich B Ernst S et al PLoS One 2014 Jul 299(7)e101002 doi 101371journalpone0101002 eCollection 2014
Anti-HDV IgM-status correlates with activity and outcomes of Hep D
Outcomes of Hep D depends on HDV genotype
G1 HDV in acute hepatitisndash A risk of fulminant failure
G1 HDV in chronic hepatitisndash Rapid progression to cirrhosisndash Risk of HCC is as many as 3 times higherndash Mortality is as many as 2 times higher
Fattovich G et al Gut 2000 46420 2 Wu Lancet 1995 3 Su et al Gastroenterol 2006 4 Wu Curr Top Micobiol Immunol 2006
Serum anti-HDV IgM is a robust marker to determine disease activity in Hep D which has prognostic implications
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Zachou K Yurdaydin С Dienes HP Manns MP et al Liver Int 2010 Mar 30(3)430-7
HDV RNA viral load did not correlate with activity
Heidrich et al Liver International 2012
Outcome of CHD does not depend on HBeAg-status
HBV DNA
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDIN 11 2016
bull 1605 patients in the database
bull Need cholinesterase for HDIN BEA fibrosis score
bull Test for liver function or hepatic reserves synthesized in hepatocytes 11 variants 20 individual variations diff stage of F0-F3 from F4 correlates with CTP MELD correlation (Pakistan AASLD 2016)
bull 63 male
bull Median age 36
bull 85 RNA +
bull 25 HBeAg(+)
bull 70 plt below 100 000 in 60
bull INR high in 70
bull 75 received INF therapy
bull 25 Nuc only Warnke AASLD 2016
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
CDC 11 2016
bull Aby Diasorin increasing prevalence via NHANEs
bull PCR LOQ is 500 copies
bull 1 step assay taqMan primers in the region of the large HDV Ag
bull 75 copies LOD
bull Range 100 and 100 M of quant
bull 49 samples since Oct 2014ndash 73 were male
ndash Median age 39 10-70 range
ndash Ethnicity wide range
ndash States in US PA 33 cases dominated
ndash Genotypes at CDC G 1 and 5 (15 cases)
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Meta-analysis antiviral treatment for chronic Hep D
GroupA
IFNa absence of antiviral Tx
3 RCT n = 137
IFNa was better for biochemical EOT [OR 011 (95 CI 004ndash02)] and virological EOT [OR 008 (95 CI 003ndash02)] but not for EOFUP VR
GroupB
Low high doses of IFNa
2 RCT n = 60
High dose IFNa was better for biochemical EOT [OR 024 (95 CI008ndash073)] and virological EOT [OR 027 (95 CI 01ndash074)]
GroupC
IFNa plusmn LAM LAM 2 RCT n = 48
No benefits
GroupD
PEG-IFNa) other antivirals
2 RCT n = 157
PEG-IFNa was better for virological EOT [OR 0419 (95 CI 018ndash0974)] EOFUP VR [OR 0404 (95 CI 0189ndash0866)] and improvement in necroinflammatory activity [OR 0308 (95 CI 0129ndash0732)]
Sources Medline Scopus Cochrane Library ISI Web of Knowledge
C Triantos M Kalafateli V Nikolopoulou A Burroughs Alimentary Pharmacology amp Therapeutics Volume 35 Issue 6 pages 663ndash673 March 2012
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Hep D Tx
bull Endpoints
ndash Eradicationsuppression of HDV replication
ndash Eradication (Functional cure) of HBV with HBsAg clearance seroconversion
ndash Normalization of biochemical tests and liver histology improvement
ndash Reset HDV RNA level reset ALT level
bull Tx
ndash PEG-IFN 48 wks (may require gt 1 year due to some advantages)
ndash AN therapy may be considered in patients with active HBV replication with a persistent or fluctuating HBV DNA gt 2000 IU ml
ndash VR can be evaluated after 3-6 months of therapy by measuring the level of HDV RNA
bull Predictors of response
ndash Non 1 genotype
ndash Initial viral load lt 106 copiesml
ndash PCR HDV RNA (--ve) at month 6 of Tx
ndash Lower Initial HBsAg titer
EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection Journal of Hepatology 2012 vol 57 p 167ndash185 Hughes S EASL monothematic conferenceldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr138 Stern EASL monothematic conference ldquoDelta Hepatitisrdquo Istanbul Turkey September 24-26 2010 Abstr186 Castelnau et al Hepatology 2006
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDV Tx (Cont)
bull Trials with PEG-IFNa showed HDV RNA negativity rates of 25-30 24 weeks after therapy
bull Therapy up to 5 years can result in 35 long-term SVR
bull Retrospective-prospective follow-up of 77 patients in the HIDIT-1 trial with a median time of follow-up of 45 (05-55) yearsndash Out of 16 patients tested HDV RNA-
negative 6 months after PEG-IFNa treatment 9 individuals tested HDV RNA-positive in the long-term follow-up study
Heidrich B1 Yurdaydın C Kabaccedilam G et al Hepatology 2014 Jul60(1)87-97 doi 101002hep27102 Yurdaydin in press 2016
Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virologicalresponse should be avoided in HDV infection
bull Kazakhstanndash 11 cases were analyzedndash Tx
Peg-IFNα 2a 180 microgwk 48 wks (in 1 case ndash 36 wks)
ndash Efficacy EOT VR ndash in 4 out of 11 pts (364) VR at 6 months follow up ndash in 3 pts (273) VR after 6 months follow up ndash in 2 pts (180)
A Nersesov Zh Kaibullayeva ARaissova AEDzhumabaeva et al The Liver Week 2014 Jeju Korea Abstract book P 176
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
The Hep-Net-International Delta-HepatitisIntervention Trial 2 HIDIT-2
Endpoints Peg-IFN α2a + TDF
Peg-IFN α2a + Placebo
P
Not detected HDV RNA At the end of 96 weeks of treatment
47 33 NS
Of those who completed treatment 54 41 NS
24-week post-treatment sustained response 30 23 NS
Relapse 44 40 NS
darrHBsAg gt05 log IUmL At week 96 30 25 NS
At week120 22 25 NS Lower HDV RNA and lower HBsAg levels at baseline were associated with HDV sustained virological response
People with cirrhosis had a higher HDV virological response rate compared with non-cirrhotics (51 vs 25 respectively)
Prolonged pegylated interferon plus tenofovir was difficult to tolerate and did not have any benefit
All participants had at least 1 adverse event and one-third had serious adverse events
H Wedemeyer C Yurdaydin S Ernst et al EASL 2014
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
New treatments
bull The drug Ezetimibe which is currently known to lower cholesterol is being used in a trial in Pakistan for patients with chronic HDV (phase II) httpsclinicaltrialsgovct2showNCT03099278term=hepatitis+Damprank=4
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Liver Transplant for HDV-infection
bull The only available option for pts with FHF end-stage liver disease and HDV-associated HCC who are not candidates for resection
bull LT for HDV The best outcomes amongst all other viral hepatitis (including HBV monoinfection)
bull Compared to HBV monoinfection in HDV infection the HBV graft infection risk is lower
bull With the prophylactic HBIg and NAs the incidence of HBVHDV graft infection is 0-5
bull After LT the long term prophylaxis of HBV graft infection is recommended
bull There is no any effective treatment of graft HDV infection
ten Kate FJ Schalm SW Willemse PJ et al J Hepatol 142-3 1992 Mar 168-75 Samuel D Muller R Alexander G et al N Engl J Med 1993 3291842-7 Smedile A Casey JL Cote PJ et al Hepatology 1998271723-9 Rifai K Wedemeyer H Rosenau J et al Clin Transplant 2007 21(2) 258$ Roche B Samuel D Seminars in liver disease 323 2012 Aug pg 245-55 Wedemeyer H Hepatology Clinical textbook Flying publisher 2012 546 p
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Under Utilization of Hepatitis D Virus Testing among HBV Monoinfected and HBVHIV
Coinfected Patients
Parham Safaie MD
Isaac Privatera
Kenneth E Sherman MD PhD
Division of Digestive Diseases University of Cincinnati College of Medicine- Cincinnati Ohio
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
GoalsHypothesis
bull Determine frequency of testing for HDV among those with HBV infection
bull Whether HIV-infected persons will have higher rates of testing than those without HIV
bull Whether GastroenterologistsHepatologists will order HDV tests more frequently than other physician groups
bull Determine prevalence of HDV among tested HBsAg positive persons
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Methods
bull Extracted de-identified data of all subjects with a positive HBsAg in our electronic medical record system (EPIC)
bull Examined characteristics of individuals with and without testing for multiple parameters including
ndash Agendash Genderndash Racendash Relationship with serum aminotransferasesndash HBeAg-statusndash HBV DNAndash IVDUndash Clinician by which the HDV antibody testing was ordered
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Statistics
bull Parametric and non-parametric comparisons were performed as appropriate to the data using Statistix 100
bull A p-value of 005 was considered significant
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
RESULTSDemographics
N= 1007 HBsAg Positive Persons
Gender 386 Females (38)621 Males (61)
Race Whites (53)Black (29)Asian amp Others (18)
IVDU ndashreported for 886 (88) 7 IVDU (08)879 non-IVDU (992)
Female partners - reported for 886 (88) 85 (96)
Male partners - reported for 886 (88) 103 (116)
HIV status HIV Positive 155 (154) HIV Negative 852 (846)
HBeAg status - reported for 482 (48) 287 Negative (595)195 Positive (405)
HBeAb status ndash reported for 455 (45) 195 Negative (42)260 Positive (571)
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
RESULTS
1007 HBsAg+
HDV Ab - reported only for 121 (12)
117 Negative (967) 4 Positive (33)
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
RESULTS (Cont)
1007 HBsAg (+)
852 (846) HIV Negative
113 Tested for HDV Ab(132)
155 (154) HIV Positive
8 Tested for HDV Ab (51)
All HDV Ab Negative4 HDV Ab Positive (33)
P= 0003
ns
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
CHACTERISTICS by HDV STATUS(for the 121 subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
Age 57 458 ns
ALT (Mean) 343(SE + 44708)
314(SE+ 826)
ns
IVDU 0 2 ns
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 81
P value
HBV DNA(Available for 85 patients)
625 IUmL (Mean)
427 x 106 IUmL(Mean)
002
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
CHACTERISTICS by HDV STATUS(for the 121 total subjects tested for HDV which includes 8 HIV+ subjects)
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAbNegative
0 48 ns
HBe AbPositive
3 48
Groups HDV Ab (+) N= 4
HDV Ab (-)N= 117
P value
HBeAgNegative
3 46 004
HBeAg Positive 0 64 Reported for only 113
Reported only for 99
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
TESTING By Specialty
Fre
qu
en
cy
HDVAb116 cases plotted 891 missing cases
Gastroenterology
0
20
40
60
Negative Positive
Infectious Disease
Negative Positive
Internal Medicine
0
20
40
60
Other
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Summary Sherman et al
bull HDV testing is rarely performed in HBsAg+ subjects in our system
bull Patients with HIV are less likely to have been tested than those without HIV
bull GastroenterologistHepatologists are more likely to order HDV testing than other health care providers
bull The rate of HDV positivity in a mid western city was 33 (95 CI range 09 - 82)
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Conclusions
bull HDV antibody test performance is inadequate in all groups
ndash Among tested persons rates of HDV Ab among HBsAg+ persons are higher than would be expected
Limitations of the study
ndash We do not know if the tested group was selected because of higher putative prevalence of HDV
ndash HDV RNA testing is not available routinely at many institutions including our own and should be considered
bull Targeted reminders may play a role in improving testing performance
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Efficacy of prolonged tenofovir therapy on hepatitis delta in HIV-infected patients
After a median tenofovir exposure of 58 (34ndash93)
months all patients had undetectable HBV-DNA
and 10 (53) HDV-RNA less than 10 copiesml In
the last group the median time to reach
undetectable HDV-RNA was 54 (33ndash72) months In
the remaining nine HDV viremic patients at the end
of follow-up the median HDV-RNA had dropped to
242 (127ndash309) log copiesml
Soriano Vincent Vispo Eugenia Sierra-Enguita Rociacuteo Mendoza Carmen de Fernaacutendez-Montero Joseacute V Labarga Pablo Barreiro Pabloa AIDS Issue Volume 28(16) 23 October 2014 p2389ndash2394
During tenofovir therapy there was an overallreduction in liver stiffness from a median of 219to 138 KPa (P = 034) More than 30 reductionin liver stiffness during the study period occurredin six out of 10 (60) patients who achievedundetectable HDV-RNA Regression of cirrhosiswas recognized in five patients all of whom hadachieved undetectable HDV-RNA
Conclusion Long-term exposure to tenofovir significantly reduced serum HDV-RNA apart from completely suppressing HBV-DNA in HIV-infected patients with hepatitis delta This virological benefit is accompanied by significant improvements in liver fibrosis
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Functional control and clinical benefit 1 year following completion of REP 2139 peg-IFN
therapy in patients with chronic HBV HDV co-infection
M Bazinet V Pacircntea V Cebotarescu L Cojuhari P Jimbei A Krawczyk A Vaillant
13th HDIN Meeting in Amsterdam (EASL) April 19th 2017
Infectious DiseaseClinic
Toma CiorbăHospital
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
63
Particle production in HBV
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
SUBVIRAL PARTICLES The bulk of circulating HBsAg
HBsAg is an immunosupressent
bullCapturesbinds anti-HBs response
bullBlocks signalling mechanisms in innate and adaptive immunity
bullBlocks the effect of immunotherapies
bullHBsAg clearance is critical to achieving functional control
M Bazinet et al 2016 Hepatology 64 S912AAl-Mahtab et al 2016 PLOS One 11 e0156667Shi et al 2012 PLOS One 7 e44900Woltman et al 2011 PLOS One 6 e15324Op den Brouw et al 2009 Immunology 126 280-289Wu et al 2009 Hepatology 49 1132-11 Xu et al 2009 Molecular immunology 46 2640-2646Cheng et al 2005 Journal of Hepatology 434 65-471Vanlandschoot et al 2002 J Gen Virol 83 1281-1289
cccDNA
integrated
HBsAg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
64
Infected
hepatocyt
e
Virions + filaments
HBeAg
Capsids
NAPs block subviralparticle release
(cccDNA and integration derived)
Efficient HBsAg clearancefrom the blood
Vaillant 2016 Antiviral Res 133 32-40Al-Mahtab et al 2016 PLOS One 11 e0156667M Bazinet et al 2016 AASLD Abstract 1848Reesink et al 2016 Hepatol Int 10 S2Noordeen et al 2015 PLOS One 10 e0140909
Critical effects of HBsAg clearance
bullUnmasking anti-HBs response do anti-HBs have an effect on immune control not proven
bullModulation of HBsAg mediated immunosuppression
bullMay improved response to immunotherapy
bullFunctional control may be established in more patients
Nucleic Acid Polymers (NAPs)
cccDNA
integrated
HBsAg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDIN April 19 2017 65
HBV vs HBV HDV co-infection
Infected
hepatocyt
e
Subviral particle production in HBV monoinfection
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDIN April 19 2017 66
HBV vs HBV HDV co-infection
Bonino et al 1986 J Virol 58 945-950
Infected
hepatocyt
e
HDV RNP
HDV RNA
Subviral particle production in HBV monoinfection
HDV exits the hepatocyte using the same secretory machinery as HBV subviral particles
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDIN April 19 2017 67
REP 301 301-LTF studies
Follow-up(4 12 and 24 weeks) Pegylated interferon α-2a
180 μg qW SC 48 weeks
REP 2139-Ca500mg qW IV 15 weeks
REP 2139-Ca250mg qW IV 15 weeks
bull 12 Caucasian patients with confirmed chronic HBV HDV co-infectionbull Clinicaltrialsorg NCT02233075
REP 301-LTF (NCT02876419) 3 year extension of follow-up (every 6M)
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDIN April 19 2017 68
Serum HBsAg
LLOQ = lower limit of quantification TND = target not detected (000 IUmL) EOT = end of treatment not enrolled in REP 301-LTF
HBsAg status(IUmL)
000000000
000
000
2392646
13896214
149431225
29724
24Wfollow-up
Baseline
139982726428261
12382
5854
1751116426
208698314
134307836
20473
512 patients with HBsAg control at 24W ndash 1 year follow-up
Complete HBsAg response
Partial HBsAg response
REP 2139pegIFN 1 year follow-up
000001001
003
pending
1466621
4754
149171281
pending
1 yearfollow-up
An additional 2 patients have established a new HBsAg baseline
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDIN April 19 2017 69
Serum HBV RNA
69
HBV RNA status(log copiesml)
DDL Diagnostic Rijswijk The Netherlands TND = target not detected LLOQ = lower limit of quantification (249 log copiesmL)
Baseline HBV RNA is either not quantifiable or not detectable in all patients
REP 2139
pegIFN 1 year follow-up
Baseline
TNDTNDTND
TND
TND
TNDlt LLOQ
TND
TNDTND
lt LLOQTND
24Wfollow-up
TNDTNDTND
TND
TND
TNDTND
TND
TNDTNDTNDTND
HBsAgBaseline(IUmL)
139982726428261
12382
5854
1751116426
208698314
13430
783620473
despite significant HBsAg levels
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDIN April 19 2017 70
Serum HBcrAg
HBcrAg status(log UmL)
Fujirebio Lumipulsereg (DDL Diagnostic Rijswijk The Netherlands) LLOD = lower limit of detection (2 log UmL)
Baseline
lt LLODlt LLODlt LLOD
32
45
4144
lt LLODlt LLOD
455
28
24Wfollow-up
lt LLODlt LLODlt LLOD
lt LLOD
lt LLOD
lt LLOD44
lt LLOD234543
lt LLOD
REP 2139mono
lt LLODlt LLODlt LLOD
28
4
448
lt LLOD
465115
HBsAg logreductionREP 2139
mono
418492645
609
451
237144
132411036183217
Baseline HBcrAg is undetectable in 512 patients at baseline
HBcrAg levels are unchanged during REP 2139 monotherapydespite substantial decreases in HBsAg (selective targeting of SVPs)
pegIFN results in HBcrAg lt LLOD in 45 patients with HBsAg reduction gt 2 log
REP 2139
pegIFN 1 year follow-up
lt LLOD 31
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDIN April 19 2017 71
Serum HBV RNA HBcrAg(HBeAg negative HBV mono-infection)
r2 = 090p lt 0001
r2 = 086p lt 0001
r2 = 081p lt 0001
Baseline measurements of 40 HBeAg- HBV mono-infected patients(REP 401 protocol poster THU-154)
HBV RNA deficit is specific for chronic co-infection with HDV
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDIN April 19 2017 72
Anti-HBs maintenance off treatmentversus HBsAg response
Maintenance of anti-HBs titers at 1 year follow-up is correlatedwith serum HBsAg lt 1 IU at the start of peg-INF therapy
REP 2139
pegIFN 1 year follow-up
Anti-HBs status(mIUmL)
507318735079
231
(32543)
lt 01078
lt 01lt 01011
(lt 01)
HBsAg1 year
follow-up
1 yearfollow-up
HBsAglt 1 IUmL
before pegIFN 000
001001
003
(000)
1466621
4754
149171281
(29724)
EOT = end of treatment not enrolled in REP 301-LTF (24W follow-up result 1 year follow-up result pending)
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDIN April 19 2017 73
HBV DNA
HBV DNA status(IUmL)
lt LLOQTNDTND
TND
(TND)
211696
1992
lt LLOQ10
(lt LLOQ)
1 yearfollow-up
lt LLOQlt LLOQlt LLOQ
lt LLOQ
256
726104
lt LLOQ350
lt LLOQ16NA
Baseline
EOT = end of treatment not enrolled in REP 301-LTF LLOQ = lower limit of quantitation (10 IUmL) TND = target not detectedNA = PCR result not available- inhibition observed (24W follow-up result 1 year follow-up result pending)
REP 2139
pegIFN 1 year follow-up
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDIN April 19 2017 74
Serum HDV RNA
REP 2139
pegIFN 1 year follow-up
HDV RNA status(UmL)
TNDTNDTND
TND
TND
TNDTND
TND4920TND
109x106
EOT
394x104
471x107
697x105
121x107
376x106
559x106
211x104
230x107
168x106
274x104
109x106
189x106
Baseline
TNDTNDTND
TND
TND
TND1390
465x105
TND2250
17328x106
24 weekfollow-up
TNDTNDTND
TND
pending
TND4438
TND48594
pending
1 yearfollow-up
Complete absence of HDV RNA observed at 24 weeks follow-up in 712 patientsis stable at 1 year follow-up
EOT = end of treatment early entry into REP 301 follow-up - not enrolled in REP 301-LTF TND = target not detected
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDIN April 19 2017 75
Serum ALT AST
Serum transaminases normalize in 812 patients during follow-up
EOT = end of treatment ULN = upper limit of normal
HBsAg lt 1IUmL prior to pegIFN HBsAg gt 1IUmL prior to pegIFN
Serum transaminases normalize in 2 patients with lower HBsAg set points
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
A Phase 2 Dose-Optimization Study of
Lonafarnib with Ritonavir for the Treatment of
Chronic Delta Hepatitis mdashEnd of Treatment
Results from
the LOWR HDV-2 Study
C Yurdaydin1 R Idilman1 C Kalkan1 F Karakaya1
A Caliskan1 O Keskin1 E Yurdcu1 S Karatayli1
M Bozdayi1 C Koh2 T Heller2 JS Glenn3
1Division of Gastroenterology University of Ankara Medical School Ankara Turkey 2Liver Diseases Branch
National Institute of Diabetes amp Digestive amp Kidney Diseases National Institutes of Health Bethesda
Maryland 3Division of Gastroenterology and Hepatology Stanford University School of Medicine
April 21 2017
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
bull HDV leads to the most severe form of viral hepatitis- More rapid progression to liver cirrhosis
- 5-7x more likely to develop cirrhosis and HCC vs HBV
bull HDV is always associated with HBV infection- HDV steals HBsAg from HBV for envelopment
bull Final step in replication involves prenylation- HDV hijacks prenylation a host process
bull No FDA approved Rx for HDV- PEG IFN-α demonstrates modest benefit
bull HDV worldwide prevalence is 15 - 20 million- Approximately 4-6 of HBV worldwide population is infected with HDV
- Orphan status in US and EU
largedelta
antigen
smalldelta
antigen
HDV
HBsAg
HBV
HDV
genome
Hepatitis Delta VirusLeads to the Most Severe Form of Viral Hepatitis
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
bull Small molecule oral prenylation inhibitor
bull Well-characterized through Phase 3- gt2000 patients dosed in oncology program by Merck (Schering)
- Dose limiting toxicity is GI (class effect)
bull Prenylation is a host target potential high barrier to resistance
bull Over 120 HDV patients dosed across international sites- NIH Phase 2 study results published in Lancet Infectious Diseases 2015
bull Orphan Designation in US amp EU Fast Track in US
O
NNH2
O
N
Br
N
BrCl
Well-Characterized Clinical Stage Lead Compound
Koh et al Lancet Infect Dis 2015
Sarasarreg (lonafarnib) for HDV
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
LOWR HDV ndash 4
ldquoDose-EscalationrdquoN = 15
LOWR HDV ndash 2
ldquoDose-RangingrdquoN = 58
LOWR HDV ndash 3
ldquoQD DoserdquoN = 21
LOWR HDV - 2 - 3 - 4Week 48 Results Presented at EASL 2017
Koh et al EASL 2017 Abstract LBP-519 Wedemeyer et al EASL 2017Abstract PS-039
LOWR HDV ndash 2
bull Identify LNF-RTV combination +- PEG IFN
LOWR HDV ndash 3
bull Once-daily dosing
LOWR HDV ndash 4
bull Is rapid dose-escalation possible and or required
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Purposebull To identify combination regimens of LNF and RTV PEG IFN- which
demonstrate efficacy and tolerability for longer term dosing to enable
HDV-RNA clearance
Patients and Methodsbull Treatment duration 12 or 24 or 48 weeks
bull 72 hour PK and PD evaluation on day 1 and day 28
bull Testing frequency days 1 2 3 7 14 28 and then 4W
ndash Biochemical parameters HBV DNA
ndash HDV-RNA (by in-house qPCR with LOQ ~ 3 log copiesmL)
LOWR HDV ndash 2 StudyLOnafarnib With Ritonavir PEG IFN-
LOQ = limit of quantitation
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
High Dose
Weeks 13-24-48Weeks 1-12
or
LNF 25 mg BID
LNF ge 75 mg BID + RTV
or
LNF 25 mg BID
+ RTV 100 mg BID
+ RTV 100 mg BID + PEG IFN α 180 mcg QW
Low DoseAll-Oral
LNF 50 mg BID
Low Dose Triple Combination
LNF 50 mg BID
N=20
N=19
N=19
N=58
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyTolerability Longer Dosing and Triple Combination
8
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
LOWR HDV ndash 2 ldquoDose Findingrdquo StudyLow Doses Tested for Longer Durations
Regimen Duration (Weeks) Patients
Discontin
uations
Due toAE
L100B + R100Q 12 4 1
L150Q + R100Q 12 3 0
L100B + R50B 12 4 0
L100Q + R100Q 12 5 2
L75B + R100B
(+ P180QW on Wk 12)24 3 0
L50B + R100B
(+ P180QW on Wk 12)24 5 1
L50B + R100B24 12 0
48 2 0
L25B + R100B24 1 0
48 5 0
L50B + R100B + P180QW24 3 1
48 2 0
L25B + R100B + P180QW24 6 1
48 3 0
Total 58 6
Hig
h D
os
eL
ow
Do
se
N
= 3
4
L=LNF in mg R=RTV in mg P=PEG IFN- in mcg B=BID Q=QD9
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Characteristic Values
N 27
Median age years (range) 50 (24 - 59)
Male n () 12 (44)
Race n ()
White 27 (100)
Median BMI kgm2 (range) 245 (185 ndash 339)
Median HDV-RNA log10 copiesmL (range) 536 (330 ndash 694)
Median ALT UmL (range) 64 (24 - 229)
Prior interferon treatment n () 12 (44)
Baseline CharacteristicsLOWR HDV ndash 2 Low Dose Groups
Excludes 7 patients lt LOQ at baseline10
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 24 Weeks
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
24 Week Dosing
bull All-oral LNF 25 and 50 mg BID + RTV suppress HDV-RNA lt LOQ in 36 of patients
bull Addition of PEG IFN to LNF 25 mg BID + RTV enhances antiviral activity
84 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
LNF 25 mg BID + RTV + PEG2 Patients HDV-RNA negative at EOT (Week 24) and Week 48
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
bull 3 of 5 patients (60) PCR-negative at Week 24
- 2 had low viremia off-therapy PCR-negative at 24 weeks post-treatment
- 1 continued treatment for another 24 weeks
85 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL)
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
LOWR HDV ndash 2 EfficacyAs-Treated Analysis Patients Dosed for 48 Weeks
48 Week Dosing
bull All-oral LNF 3 of 7 patients (43) lt LOQ
bull Triple LNF 25 mg BID + RTV + PEG 2 of 3 patients (67) PCR-negative
of Patients
All-Oral Rx Triple Rx
LNF 25 mg BID
+ RTV
LNF 50 mg BID
+ RTV
LNF 25 mg BID
+ RTV + PEG
LNF 50 mg BID
+ RTV +
PEG
Week 24 N = 6 N = 8 N = 5 N = 4
HDV-RNA lt LOQ 3 6 2 8 4 5 3 4
HDV-RNA PCR
negative0 6 1 8 3 5 0 4
gt 2 log decline 3 5 1 3 3 4 3 3
Week 48 N = 5 N = 2 N = 3 N = 2
HDV-RNA lt LOQ 2 5 1 2 u 2 3 0 2
HDV-RNA PCR
negative0 5 0 2 u 2 3 0 2
gt 2 log decline 1 4 0 0 3 3 0 2
86 Patients with high baseline viral load (HDV RNA gt 5 log copiesmL) w Week 40-44 data
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
0
Week 24Baseline
P
atie
nts
with
Ele
va
ted
ALT
20
80
100
40Elevated
40
60
100Elevated
LNF 25 and 50 mg BID regimens with elevated ALT at baseline
All-Oral Rx = LNF 2550 mg BID + RTV 100 mg BID Triple Rx = LNF 2550 mg BID + RTV 100 mg BID + PEG IFN 180 mcg QW
60-78 of Patients Normalized ALT at Wk 24Addition of PEG Improves ALTNormalization
Week 24
22Elevated
100Elevated
Baseline
All-Oral Rx Triple Rx
60Normal
78Normal
N = 15 N = 9
14
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Highest grade GI AE reported1 Most common and severe reported AEs nausea diarrhea fatigue weight loss anorexiavomiting2 Includes cohort LNF 50 mg BID + RTV for first 12 weeks + PEG for second 12 weeks3 All reported to be ldquounlikely related to LNFrdquo
of Patients ExperiencingAE1
All-Oral Rx Triple Rx
AE GradeLNF 25 mg BID
+ RTV
N = 6
LNF 50 mg BID
+ RTV
N = 14
LNF 25 mg BID
+ RTV + PEG N
= 9
LNF 50 mg BID +
RTV + PEG2
N = 10
Grade 1 3 8 4 5
Grade 2 1 3 2 4
Grade 3 2 2 0 1
SAE3 1 2 1 1
Adverse Events Low Dose LNFLNF 25 50 mg Regimens Demonstrate Tolerability
15
bull AEs predominantly mild moderate for LNF 25 50 mg regimens
bull Generally tolerable through Week 48
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
LOWR HDV ndash 2Conclusions
bull All-oral LNF 25 or 50 mg BID + RTV suppresses HDV-RNA lt LOQ
- 5 of 14 (36) patients lt LOQ at Week 24
- 1 patient PCR-negative at Week 24
bull Addition of PEG IFN to LNF 25 mg BID + RTV results in highest response
- 4 of 5 (80) patients lt LOQ at Week 24
- 3 of 5 (60) patients PCR-negative at Week 24
2 patients PCR-negative at 24 weeks post-treatment
bull 60-78 of patients normalized ALT at Week 24
bull gt 2 log decline AND normalized ALT warrants evaluation for clinical benefit
bull AEs predominantly mild moderate for LNF 25 50 mg regimens16
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDIN April 19 2017 90
Summary
bull HDV suppression of HBV may target HBV pregenomic RNA
bull HDV infection can persist in the absence of active cccDNA probably using integrated HBV DNA and mRNA transcripts to make HBsAg
bull Bulk of HBsAg in chronic co-infected patients is derived from integrated HBsAg
bull REP 2139 simultaneously reduces HBsAg and HDV RNA
bull HBsAg clearance threshold for activation of immunotherapy appears to be lt 1 IU ml
bull Functional control of HBV infection in 512 patients and control of HDV infection in 712 patients is stable 1 year off-treatment
bull Functional control rate expected to be higher with longer concomitant therapy with REP 2139 and peg-IFN and including TDF
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDV Assays in the US
bull ARUP has launched a qHDV RNA test that is available at no cost to registered participants
bull Launch of commercial assay to the general medical community occurred simultaneously
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Program sponsor
HDV Awareness and Testing Program Roles
Patient HCP
education
Centralized HDV
testing
Test HBV patientsProviders
13
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Hepatitis Delta Total Antibody (IgM and IgG) bull Qualitative enzyme immunoassay
bull Detects but does not differentiate IgM and IgG
bull Results reported as lsquonegativersquo lsquopositiversquo or equivocal
bull Performance characteristics are similar to other commercially available HDV antibody tests
HDV Viral Load by PCRbull Real time RT-PCR that quantifies HDV RNA
bull Internal control monitors nucleic acid extraction and detects PCR inhibitors
bull Calibrated to WHO standard
bull Dynamic quantitative range of 120 - 5800000 IUmL
bull Lower limit of detection = 62 IUmL
Hepatitis Delta TestingARUP Laboratories
This test was developed and its performance characteristics determined by ARUP Laboratories
The U S Food and Drug Administration has not approved or cleared this test
1042017 93
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Perspectives of the Hep D therapy
bull Other IFNsndash IFN λ
ndash (Albuferon)
bull Combination therapyndash IFN with NA other agents
bull Specific agentsndash Myrcludex B (inhibitor of HBV and HDV
penetration)
ndash Prenylation inhibitors lonafarnib
ndash Replicor NAP release inhibitor
bull Improvement of liver transplant outcomes
bull Hepatology and medical support
bull Lonafarnib trialndash Oral prenylation inhibitor
ndash 14 patients were enrolled of whom eight were assigned to group 1 and six were assigned to group 2 (placebo control)
ndash lonafarnib effectiveness in blocking HDV production was greater in group 2 than in group 1 (0middot952 [SE 0middot06] vs 0middot739 [0middot05] plt0middot001) and the HDV half-life was 1middot62 days (0middot07)
ndash There was no evidence of virological resistance
ndash Adverse events were mainly mild to moderate no treatment discontinuations occurred in any treatment groups
Koh C Canini L Dahari H Zhao X et al The Lancet infectious diseases Volume 15 No 10 p1167ndash1174 October 2015
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Conclusions 1
bull HDV-infection plays an important role in the etiology of liver diseases in various parts of the world
bull All at risk HBsAg-positive patients should be tested for anti-HDV using serology and confirmation with HDV RNA by quant PCR cirrhosis geography risk behavior abnl ALT on nuc suppressed HBV patients
bull Clinical outcomes of HDV-infection depend on time interval of HBV- and HDV-infections (co- or superinfection) viral and host factors
bull Outcome of CHD superinfection is characterized by rapid progression to cirrhosis end stage liver disease and HCC
bull Peg-IFNα is the only antiviral for the ldquotreatmentrdquo of CHD and its efficacy (cure rate) is less than 15-25 with one year of treatmentndash Although emerging data in Turkey may show up to a 35-40 MVR rate with treatment up to 5 years
ndash New reset HDV RNA suppression by 1-2 logs off treatment with normal or improved ALT and improved histology
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Conclusions 2
bull Prevention HDV = vaccination against HBV and harm reduction
bull HDV LT with CHD is characterized by better outcomes compare to other HBV monoinfection
bull HDV SVR after 48-week PEG IFNa Tx is lt25
bull Most often HDV dominates over HBV but in HBV DNA-positive cases providers can use HBV-polymerase inhibitors
bull Combination of PEG IFNa and NAs does not improve treatment results
bull Late HDV RNA relapses may occur after PEG-IFNa therapy of hepatitis delta and thus the term sustained virological response (new term MVR Maintained Virologic Response) should be avoided in HDV infection
bull Treatment up to 5 years would be consider optimal with on treatment monitoring of HDV RNA q until we have new oralinjectable therapies that can clear HBsAg or HDV RNA cure
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDV Testing
Dr David Hillyard
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Laboratory Tools for HDV Diagnosis and Monitoring
bull Screen with sensitive antibody assayndash IgG and IgM
bull Confirm with sensitive RNA assayndash pan-genotypic -calibrated to WHO standard
bull Reflex Antibody to RNA assay streamlines testing
bull Monitor therapeutic response with quantitative RNA assay
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Virologic and Serologic Markers of HDV Infection
Coinfection Superinfection
M Rizzetto Cold Spring Harbor Perspect Med 20155a021576
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Comparison HDV Enzyme Immunoassays
Siu-Kei et al August 2016 Volume 23 Number 8 Clinical and Vaccine Immunology
bull Diasorin research assay is standard of performance (not available for clinical testing)
bull ARUP assay (International Immuno-Diagnostics)bull And Focus LDT test both performed well with different cutoffs
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDV RNA Testing
bull Confirm serologybull Provide baseline for monitoring course of
treatmentbull Result expressed in international units (IU)bull Calibrated to WHO international Standard
ndash Lyophilized patient plasma samplendash Vials back gassed (stable for years)ndash Limited availability ndash Secondary standards calibrated by qPCR or digital PCR)
bull Genotyping Epidemiology only
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
ARUP HDV RNA Assay
bull Two Target TaqMan qPCR
bull Calibrated to WHO standard
bull Secondary standards stored liquid nitrogen
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
HDV International Standard
Accurately characterized by Sanger and NGS sequencing
Patient sample (genotype I)IU is average of RNA copy assays1 IU is ~ 10 RNA copies
Pyne et al J Clin Virol 2017 May9052-56
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Hepatitis Delta TestingARUP Laboratories
Hepatitis Delta Total Antibody (IgM and IgG) bull qualitative enzyme immunoassaybull detects but does not differentiate IgM and IgGbull results reported as lsquonegativersquo lsquopositiversquo or equivocalbull performance characteristics are similar to other commercially
available HDV antibody tests
HDV Viral Load by PCRbull real time RT-PCR that quantifies HDV RNAbull internal control monitors nucleic acid extraction and detects PCR
inhibitorsbull calibrated to WHO standardbull quantitative range 120-6800000 IUmlbull detects as few as 62 IUml
1042017 104
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Hepatitis Delta TestingARUP Laboratories
When to order testingbull Recent diagnosis of acute HBVbull Recent presentation of acute hepatitis in a chronic HBV carrierbull HBsAg positive patient with chronic liver disease
Features and benefits of HDV testing at ARUPbull HDV seropositive samples are automatically reflexed to PCRbull Confirm active infection and monitor viral replication bull Medical Director review and consultation available
1051042017 105
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen (preferred) or refrigerated serum (2 ml)
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR for HDV RNA
Hepatitis Delta Viral Load AssayARUP Laboratories
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Test Code Test Name Method
2013880 Hepatitis Delta Virus Antibody (IgG and IgM)
Reflex to
Hepatitis Delta Viral Load by PCR
Enzyme Immunoassay
Quantitative RT-PCR
Hepatitis D Testing DetailsHepatitis D testing should only be performed in patients with documented acute or chronic Hepatitis B
SpecimenFrozen serum (2ml)
Hepatitis Delta Viral Load AssayARUP Laboratories
wwwaruplabcom2013881
Reflex TestingSamples that are positive for HDV antibodies will automatically be tested by quantitative PCR
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
Please submit questions for Dr Gish and Dr Hillyard in the chat box
Q amp A
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
THANK YOU
Please complete the post-webinar survey
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg
hepdconnect
For more information about the Hepatitis B Foundationrsquos Hepatitis Delta Connect Program visit our website
wwwhepdconnectorg